Self-Administered Drug Exclusion List: (A53033) - R32 - Effective August 20, 2023

This coverage article has been revised and published for notice under contract numbers: 02101 (AK), 02201 (ID), 02301 (OR), 02401 (WA), 03101 (AZ), 03201 (MT), 03301 (ND), 03401 (SD), 03501 (UT), and 03601 (WY).

Effective Date: August 20, 2023

Summary of Article Changes:

This article has been updated to add: J1811 insulin (Fiasp®), J1812 insulin (Fiasp®), J1813 insulin (Lyumjev®), J1814 (Lyumjev®) 100 IU*, J1814 (Lyumjev®) 200 IU, and J1941 furosemide (Furoscix®) effective for dates of service on or after 08/20/2023.

Q5131 Adalimumab-aacf (Idacio®) effective for dates of service on or after 07/01/2023.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

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