Self-Administered Drug Exclusion List: and Biologicals Excluded from Coverage - Medical Policy Article

Medicare does not cover drugs listed on the Self-Administered Drug (Usually Self-Administered) exclusion list; subcutaneous forms of drugs on that list are specifically denied. Drugs that have one HCPCS code but multiple routes must be billed with JA (IV) or JB (SC) modifiers; IV claims with JA are evaluated for coverage on medical-necessity grounds, while claims missing required modifiers or SC forms on the SAD list will be denied. Contractors follow Part B MAC coverage decisions and should use the referenced process document and HCPCS/brand-name information when adjudicating claims.

"Drugs billed with the JA modifier (intravenous infusion) are not considered part of the Self-Administered Drug (SAD) exclusion and may be covered when both the drug and the intravenous route are me..."

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