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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

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