Self-Administered Drug Exclusion List:

Noridian presumes IV and IM parenteral administration and acute short‑course or acute‑setting use (e.g., ED, pre-op, chemotherapy) are 'not usually self‑administered' and therefore meet the Medicare outpatient drug benefit, while drugs self‑administered by >50% of Medicare beneficiaries or administered subcutaneously are generally excluded. Providers must document route, indication, setting, frequency, and duration, use required HCPCS modifiers (JA/JB) for multi-route drugs, and may submit objective evidence (peer‑reviewed literature, guidelines, FDA label, package insert) for reconsideration; incorrect billing codes or missing modifiers for excluded drugs will be denied. Insulin in any form is explicitly non‑reimbursable by Medicare and listed excluded drugs are denied after a 45‑day notice period.

"Drugs administered intravenously (IV) are presumed to be 'not usually self-administered' by Medicare beneficiaries and therefore meet the Medicare Part A/B outpatient benefit category (covered when..."