Self-Administered Drug Exclusion List: Medical Policy Article

Coverage for self-administered drugs for both Part A and Part B is determined by the MAC Contractor in each jurisdiction. HCPCS codes used under Outpatient Prospective Payment System (OPPS) are included, in addition to the codes used for Part B claims, when appropriate. The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see “Process for Determining Self-Administered Drug Exclusions – Medical Policy Article”). The column, “Brand Names,” provides one or more examples but may not include all brand names. Information about drugs not separately reimbursed or not covered for reasons other than “usually self-administered,” is detailed in Part A and Part B MAC publications and postings available elsewhere. Route of Administration Modifier The use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection form of administration. Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied. NOTE: The drugs represented by HCPCS codes J0801 and J0802 (marked with a double asterisk **) are administered by IM or SQ, therefore they require the JB modifier to be reported for SQ administration and they should not have any modifier reported for the IM administration.