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Self-Administered Drugs List

Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Comments
J0135 INJECTION, ADALIMUMAB, 20 MG Humira 09/21/2003 N/A Apparent on its face/USA/SC every other week
J0270 Alprostadil, 1.25 MCG Caverject, Prostaglandins, Edex 01/01/2007 N/A Apparent on its face/USA/ Intracavernosal or Intraurethral/ Use as Needed
J0275 Alprostadil urethral suppository Muse 01/01/2007 N/A Apparent on its face/USA/ Intracavernosal / Use as Needed
J3490/ J3590 Anakinra Kineret 10/30/2010 N/A Frequency/Apparent on its face/USA/SC Daily or Every Other Day
J0364 Apomorphine Hydrochloride Apokyn 01/01/2007 NA Frequency/Apparent on its face/USA/ SC Daily
J3490 Becaplerim, a self-administered, non-autologous growth factor for chronic, nonhealing, subcutaneous wounds, is nationally non-covered   04/27/2006 N/A Based on CMS National Coverage Decisions Manual 100-03 section 270.3.
J0630 Calcitonin Salmon Miacalcin, Fortical 01/01/1982 N/A Frequency/Apparent on its face/USA/ SC as needed
J3490/ J3590 Chorionic Gonadotropin Alfa, Recombinant Ovidrel 01/01/2008 N/A Administered SC by the patient, based on labeled instruction from manufacturer
J3490/ J3590 Efalizumab Raptiva 10/30/2010 N/A Administered SC weekly by the patient or caregiver, based on labeled instruction from manufacturer
J1324 Enfuvirtide Fuzeon 01/01/2007 N/A Frequency/Apparent on its face/USA/SC twice daily
J1438 Etanercept Enbrel 01/01/2003 N/A Frequency/Apparent on its face/USA/SC twice a week
J3490/ J3590 Exenatide Byetta 10/30/2010 N/A Apparent on its face/USA/SC twice daily
J1595 Glatiramer Acetate Copaxone 01/01/2003 N/A Frequency/Apparent on its face/USA/ SC Daily
J1675 Histrelin Acetate   01/01/2000 N/A Frequency/Apparent on its face/USA/ SC Daily
J3490 Kutapressin   01/01/2003 N/A Frequency/USA/ SC or IM Daily
J9218 Leuprolide Acetate Injection - 1 mg. daily subcutaneous Lupron 01/01/1990 N/A Frequency/Apparent on its face/USA/ SC Daily
J2170 Mecasermin Increlex, Iplex 01/01/2007 N/A Frequency/Apparent on its face/USA/SC Daily
J3490 Pegvisomant for injection Somavert 07/20/2003 N/A Frequency/Apparent on its face/USA/SC Daily
J2354 Octreotide Acetate, non-depot form Sandostatin 10/30/2010 N/A Frequency/Apparent on its Face/USA/SC 2 to 4 times daily
J2940 Somatrem   01/01/2003 N/A Frequency/Apparent on its face/USA/ SC or IM Daily
J2941 Somatropin, Inj. Genotropin, Humatrope, Norditropin, Nutropin AQ, Saizen, Serostim 01/01/2003 N/A Apparent on its face/Frequency/USA/SC Daily/SC or IM 3 times weekly
J3030 Sumatriptan Succinate Imitrex 01/01/1995 N/A Apparent on its face/USA/SC as needed
J3110 Teriparatide Forteo 07/20/2003 N/A Frequency/Apparent on its face/USA/SC Daily

Contractors must provide notice 45 days prior to the date a drug will be excluded/not covered. During the 45 day time period, contractors will maintain existing medical review and payment procedures.

Comment Period: 09/14/2010 through 10/29/2010

Update Effective: 10/30/2010

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