Article for Self-Administered Drugs and Biologicals Excluded from Coverage – Medical Policy Article (A38534)

Contractor Information

Contractor Name 

National Government Services, Inc.  

Contractor Number 

00803 

Contractor Type 

Carrier 

Article Information

Article ID Number 

A38534 

Article Type 

SAD Exclusion Article

Key Article 

Yes

Article Title 

Self-Administered Drugs and Biologicals Excluded from Coverage – Medical Policy Article 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction 

New York - Downstate

Original Article Effective Date 

10/01/2002

Article Revision Effective Date 

07/01/2008

Article Text 

The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see Process for Determining Self-Administered Drug Exclusions – Medical Policy Article). The column, “Brand Names,” provides one or more examples but not all. Information about drugs not separately reimbursed or not covered for reasons other than “usually self-administered,” is found in other carrier and fiscal intermediary publications and sites.

Coverage Topic 

Prescription Drugs

Coding Information

No Coding Information has been entered in this section of the article.

Coding Table Information

CPT/HCPCS Codes - Table Format 

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Comments
J0135	INJECTION, ADALIMUMAB, 20 MG	Humira	12/06/2003	N/A	Non-acute subcutaneous (SC) injection by patient, weekly or every other week.
J0270	INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Caverject, Edex	11/14/2002	N/A	Usually self-injected by patient on an "as-needed basis".
J0275	ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Muse	11/14/2002	N/A	Suppository
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Calcimar, Miacalcin	11/14/2002	N/A	Non-acute subcutaneous (SC) injection by patient, daily or every other day.
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Fuzeon	02/15/2007	N/A	Non-acute subcutaneous (SC) injection by patient, twice daily.
J1438	INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Enbrel	11/14/2002	N/A	Non-acute subcutaneous (SC) injection by patient, usually twice a week.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Copaxone	02/07/2004	N/A	Self-administration; subcutaneous 20 mg/day
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Supprelin	05/16/2007	N/A	Non-acute subcutaneous administration, usually once daily by patient
J1815	INJECTION, INSULIN, PER 5 UNITS	Humalog, Humulin, Iletin, Insulin Lispo, Novo Nordisk, NPH, Pork Insulin, Regular Insulin, Ultralente, Velosulin, Humulin R, Iletin II Regular Port, Insulin Purified Pork, Relion, Lente Iletin I, Novolin R, Humulin R U-500	11/14/2002	N/A	Non-acute subcutaneous (SC) injection by patient, every day.
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Humalog, Humulin, Vesolin BR, Iletin II NPH Pork, Lantus, Lispro-PFC, Novolin, Novolog, Novolog Flexpen, Novolog Mix, Relion Novolin	11/14/2002	N/A	Non-acute chronic filling of pump by patient.
J1830	INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Betaseron	11/14/2002	N/A	Non-acute subcutaneous (SC) injection by patient, usually every other day.
J2170	INJECTION, MECASERMIN, 1 MG	Increlex, Iplex	02/15/2007	N/A	Non-acute subcutaneous injection twice daily by patient.
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Sandostatin	11/14/2002	N/A	Usually self-administered injections two to four times daily, depending on the indication.
J2940	INJECTION, SOMATREM, 1 MG	Protropin	11/14/2002	N/A	Non-acute subcutaneous (SC) injection by patient, several time a week.
J2941	INJECTION, SOMATROPIN, 1 MG	Genotropin	11/14/2002	N/A	Non-acute subcutaneous (SC) injection by patient, several time a week.
J3030	INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Imitrex	11/14/2002	N/A	Subcutaneous (SC) injection by patient at onset of symptoms (up to two times in a 24-hour period).
J3110	INJECTION, TERIPARATIDE, 10 MCG	Forteo	12/06/2003	N/A	Non-acute, subcutaneous (SC) injection into thigh or abdomen (lower stomach area) once a day by patient using multidose prefilled delivery device (FORTEO pen - contains 28 daily doses).
J3490	UNCLASSIFIED DRUGS	Byetta (exenatide)	09/01/2006	N/A	Non-acute subcutaneous (SC) injection by patient, within the 60-minute period before morning and evening meals.
J3490	UNCLASSIFIED DRUGS	Symlin (Pramlintide acetate)	05/16/2007	N/A	Non-acute subcutaneous (SC) injection by patient, immediately prior to major meals.
J3590	UNCLASSIFIED BIOLOGICS	Kineret	05/16/2007	N/A	Non-acute subcutaneous (SC) injection by patient, every day.
J3590	UNCLASSIFIED BIOLOGICS	Peg-Intron	12/06/2003	N/A	Subcutaneous weekly administration for one year by patient.
J3590	UNCLASSIFIED BIOLOGICS	Pegasys	12/06/2003	N/A	Subcutaneous weekly administration for 48 weeks by patient.
J3590	UNCLASSIFIED BIOLOGICS	Raptiva	02/07/2004	N/A	Non-acute subcutaneous weekly injection by patient.
J3590	UNCLASSIFIED BIOLOGICS	Somavert	05/16/2007	N/A	Non-acute subcutaneous injection daily, by patient.
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Infergen	12/06/2003	N/A	Subcutaneous administration three times per week for 24-48 weeks, by patient.
J9213	INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS	Roferon A	12/06/2003	N/A	Hepatitis C: Subcutaneous administration three times per week for 12 months by patient. Hairy cell leukemia: Subcutaneous administration daily for 16 - 24 weeks and three times per week by patient. CML: Subcutaneous daily.
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Actimmune	12/06/2003	N/A	Non-acute subcutaneous administration usually three times per week by patient.
J9218	LEUPROLIDE ACETATE, PER 1 MG	Lupron	11/14/2002	N/A	Non-acute, usually daily subcutaneous (SC) injection by patient.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Geref	03/06/2006	N/A	Non-acute subcutaneous daily administration by patient.

Other Information

Other Comments 

01/29/2005 - CPT/HCPCS code J1820 was deleted from the Code Table

Revision History Explanation 

Article Published July 2008:
The article text paragraph has been revised to remove information that can be found in the article titled “Process For Determining Self-Administered Drugs Exclusions – Medical Policy Article”. As part of the National Government Services consolidation process, the title has also been revised.

Added "Medical Policy Article" to the title

Article Published 04/01/2007:
Removed J0945 (Brompheniramine maleate) effective 04/01/2007
Added the following drugs effective 05/16/2007: Supprelin (J1675 - Histrelin Acetate, 10mg); Symlin (J3490 - unclassified drugs); Kineret (J3590 - unclassified biologics); Somavert (J3590 - unclassified biologics)

Related Documents 

Article(s)
A47521 - Process for Determining Self-Administered Drug Exclusions – Medical Policy Article