Self-Administered Drug Exclusion List (A53033) - R45 - Effective January 1, 2026

Date Posted: January 2, 2026

This billing and coding article has been revised and published for notice under contract numbers: 02102 (AK), 02202 (ID), 02302 (OR), 02402 (WA), 03102 (AZ), 03202 (MT), 03302 (ND), 03402 (SD), 03502 (UT), and 03602 (WY).

Effective Date: January 1, 2026

Summary of Changes:

EXCLUDED CPT/HCPCS CODES:

Deleted: J2940 Somatrem, 1 mg (Protropin); J3355 Urofollitropin, 75 IU (Metrodin, Bravelle, Ferinex); and J9212 Interferon Alfacon-1, Recombinant, 1 microgram (Infergen)

NON-EXCLUDED CPT/HCPCS CODES:

Deleted: J1562 Injection, Immune Globulin (Vivaglobin), 100 mg

Visit the Self-Administered Drugs (SADs) webpage to view the Self-Administered Drug Exclusion List.

To view the complete listing of billing and coding articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Billing and Coding Articles webpage.

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