Self-Administered Drug Exclusion List: (A53032) - R30 - Effective August 20, 2023

This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

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.

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Last Updated Jul 06 , 2023