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

