February 20, 2008
CIGNA Medicare Part B Carrier for Idaho, North Carolina, and Tennessee Usually Self Administered Drug Report 01/17/2008
| HCPCS | Descriptor | Effective Date of Exclusion | End Date of Exclusion | Comments |
|---|---|---|---|---|
| J0135 | Adalimumab (Humira) | 09/21/2003 | N/A | Apparent on its face/USA/SC every other week |
| J0270 | Alprostadil (Caverject, Prostaglandins, Muse) | 01/01/1997 | N/A | Apparent on its face/USA/ Intracavernosal or Intraurethral/ Use as Needed |
| J0364 | Apomorphine Hydrochloride (Apokyn) | 01/01/2007 | N/A | Frequency/Apparent on it 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 | 01/01/1982 | N/A | Frequency/Apparent on its face/USA/ SC as needed |
| J3490 | Chorionic Gonadotropin Alfa, Recombinant (Ovidrel) | 01/01/2008 | N/A | Administered SC by the patient, 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 | Apparent on its face/USA/SC twice a week |
| 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 |
| J1815 | Insulin | 01/01/2003 | N/A | Frequency/Apparent on its face/USA/ SC/Daily |
| J1817 | Insulin | 01/01/2003 | 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 | 01/01/1990 | N/A | Frequency/Apparent on its face/USA/ SC Daily |
| J2170 | Mecasermin (Increlex or 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 it face/USA/SC 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 are all SC {Daily or 3 times weekly} and Nutropin Depot once monthly or twice monthly on same days {i.e., 1st & 15th}) | 01/01/2003 | N/A | Apparent on its face/Frequency/USA/SC Daily/SC or IM 3 times weekly |
| J3030 | Sumatriptan Succinate | 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: 01/01/2008 - 03/01/2008 Added Chorionic Gonadotropin Alfa, Recombinant (Ovidrel)
Update Will be Effective: 01/01/2008
