September 10, 2013
Self-Administered Drug Exclusion List and Biologicals Excluded from Coverage - Medical Policy Article (R7) – Article # A50905 - Revised
The following drugs/biologicals have been added to Article # A50905. Effective for dates of service on or after October 23, 2013, the drugs listed below will be denied as self-administrable by the patient.
- Icatibant Acetate (Firazyr) – HCPCS code J1744
- Immune Globulin (Hizentra) – HCPCS code J1559
- Immune Globulin Subcutaneous (Vivaglobin) – HCPCS code J1562
- Liraglutide- GLP-1 agonist DM (Victoza) – HCPCS code J3490
- Methylnatrexone (Relistor) – HCPCS code J2212
- Mipomersen (Kynamro) – HCPCS code J3490
- Papaverine – HCPCS code J2440
- Pasireotide (Signifor) – HCPCS code J3490
- Phentolamine Mesylate – HCPCS code J2760
- Urofollitropin – FSH (Bravelle) – HCPCS code J3355