Self-Administered Drug Exclusion List - R14, R15

The Self-Administered Drugs Exclusion List 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), 03601 (WY).

Effective Date: 09/18/19
Summary of Changes:
This article is a revision to update the effective date of the following drugs from 09/09-09/18/19 to give providers the 45-day notice.

  • J0599 - HAEGARDA
  • J3490 - Insulin Glargine (recombinant), Lantus Solostar, Adalimumab-adbm (Cyltezo)
  • J3590 - Abaloparatide (Tymlos), Sarilumab (Kevzara), Semaglutide (Ozempic), Fremanezumab-vfrm (Ajovy), Erenumab-aoooe (Aimovig), Alcanezumab-gnlm (Emgality)

View the locally hosted Self-Administered Drug Exclusion List.

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Last Updated Aug 01, 2019