Self-Administered Drug Exclusion List (A53033) - R30 - Effective November 11, 2022

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: November 11, 2022

Summary of Changes: Under Excluded CPT/HCPCS Codes added: Mounjaro™ (Tirzepatide) - C9399, J3490, J3590 effective 11/19/2022.

Under Excluded CPT/HCPCS Codes updated: Descriptor Brand Names for insulin products, the verbiage has been revised to read "All insulin products" for HCPCS codes C9399, J1815, J1817, J3490 and J3590.

The most current version of the Self-Administered Drug Exclusion List is available on the Medicare Coverage Database (MCD).

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

            Last Updated Thu, 06 Oct 2022 13:32:59 +0000