Page reviewed Jun 29, 2026 · from CMS Self-Administered Drug Exclusion articles (2026-04-19)
Self-administered? Part B or Part D?
Drugs on a SAD list
58
MAC exclusion lists
8
Basis
SSA §1861(s)(2)(B)
Excluded drug benefit
Part D (not Part B)
Recent changes to the SAD lists
Drugs that moved on or off the MAC SAD exclusion lists since our last refresh — what changed between Part B and Part D, and when.
| Effective | Drug | What changed |
|---|---|---|
| Nov 15, 2025 | J0490 Belimumab Benlysta | Route-dependent |
| Aug 31, 2025 | Q5098 Inj ustekinumab-srlf, 1 mg | Route-dependent |
| Aug 31, 2025 | Q5100 Inj ustekinumab-kfce, 1 mg | Route-dependent |
| Jul 1, 2025 | Q5099 Inj ustekinumab-stba, 1 mg | Route-dependent |
| Jun 30, 2025 | Q9999 Otulfi | Route-dependent |
| Mar 16, 2025 | J0139 Injection, adalimumab, 1 mg Humira® | Excluded (all MACs) |
| Mar 16, 2025 | Q5140 Injection, adalimumab-fkjp, biosimilar, 1 mg | Excluded (all MACs) |
| Mar 16, 2025 | Q5141 Injection, adalimumab-aaty, biosimilar, 1 mg | Excluded (all MACs) |
| Mar 16, 2025 | Q5142 Injection, adalimumab-ryvk biosimilar, 1 mg | Excluded (all MACs) |
| Mar 16, 2025 | Q5143 Injection, adalimumab-adbm, biosimilar, 1 mg | Excluded (all MACs) |
| Mar 16, 2025 | Q5144 Injection, adalimumab-aacf (idacio), biosimilar, 1 mg | Excluded (all MACs) |
| Mar 16, 2025 | Q5145 Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg | Excluded (all MACs) |
| Mar 16, 2025 | Q9996 Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg pyzchiva | Excluded (all MACs) |
| Mar 16, 2025 | Q9998 Injection, ustekinumab-aekn (selarsdi), 1 mg ustekinumab-aekn (selarsdi) | Route-dependent |
| Sep 1, 2024 | J1748 Zymfentra (infliximab-dyyb) | Route-dependent |
| Jul 1, 2024 | J2267 Omvoh mirikizumab-mrkz | Route-dependent |
| Jul 1, 2024 | Q5137 Wezlana (ustekinumab-auub) | Route-dependent |
| Oct 25, 2023 | Q0515 INJECTION, SERMORELIN ACETATE, 1 MICROGRAM Geref Diagnostic | Excluded — varies by MAC |
| Oct 1, 2023 | J0801 Acthar® Gel | Route-dependent |
| Oct 1, 2023 | J0802 Purified Cortrophin Gel ® | Route-dependent |
Generated from a snapshot diff of the CMS SAD articles — the seed of a quarterly “what moved between Part B and Part D” changes feed.
Full self-administered drug exclusion list
| HCPCS | Drug / brand | Part B status | Across MACs | Your MAC |
|---|---|---|---|---|
| J0129 | Abatacept Orencia Orencia Clickjet | Route-dependent | 8 of 8 MACs | |
| J0139 | Injection, adalimumab, 1 mg Humira® | Excluded (all MACs) | All MACs | |
| J0270 | Caverjet®, Edex® | Excluded (all MACs) | All MACs | |
| J0275 | Muse | Excluded — varies by MAC | 2 of 8 MACs | |
| J0364 | Apokyn | Excluded — varies by MAC | 7 of 8 MACs | |
| J0490 | Belimumab Benlysta | Route-dependent | 8 of 8 MACs | |
| J0593 | LANADELUMAB-FYO (Takhzyro) | Excluded — varies by MAC | 7 of 8 MACs | |
| J0599 | C1 Inhibitor (Human) Berinert Cinryze Haegarda | Excluded (all MACs) | All MACs | |
| J0630 | Calcimar Fortical-DSC Miacalcin Osteocalcin Salmonine | Excluded — varies by MAC | 7 of 8 MACs | |
| J0801 | Acthar® Gel | Route-dependent | 8 of 8 MACs | |
| J0802 | Purified Cortrophin Gel ® | Route-dependent | 8 of 8 MACs | |
| J1324 | Fuzeon | Excluded (all MACs) | All MACs | |
| J1438 | Enbrel® Enbrel Mini Enbrel Sure Click Brenzys Also see J3590 Etanercept-szzs (Erelzi) | Excluded (all MACs) | All MACs | |
| J1595 | Copaxone Glatopa | Excluded (all MACs) | All MACs | |
| J1628 | Guselkumab Tremfya | Route-dependent | 8 of 8 MACs | |
| J1675 | Supprelin | Excluded — varies by MAC | 6 of 8 MACs | |
| J1744 | Firazyr | Excluded (all MACs) | All MACs | |
| J1748 | Zymfentra (infliximab-dyyb) | Route-dependent | 7 of 8 MACs | |
| J1811 | Insulin via insulin pump (fiasp) | Excluded (all MACs) | All MACs | |
| J1812 | Inj. Insulin (fiasp) | Route-dependent | 8 of 8 MACs | |
| J1813 | Insulin via insulin pump (lyumjev) | Excluded (all MACs) | All MACs | |
| J1814 | Inj. insulin (lyumjev) U-100 and U-200 | Route-dependent | 8 of 8 MACs | |
| J1815 | All Insulin products | Excluded (all MACs) | All MACs | |
| J1817 | All Insulin Products | Excluded (all MACs) | All MACs | |
| J1826 | Avonex Pen Rebif Rebif Rebidose | Excluded — varies by MAC | 5 of 8 MACs | |
| J1830 | Betaseron® Extavia | Excluded (all MACs) | All MACs | |
| J1941 | furosemide (Furoscix) | Excluded (all MACs) | All MACs | |
| J2170 | Increlex | Excluded (all MACs) | All MACs | |
| J2212 | Relistor | Excluded (all MACs) | All MACs | |
| J2267 | Omvoh mirikizumab-mrkz | Route-dependent | 8 of 8 MACs | |
| J2354 | Sandostatin | Route-dependent | 8 of 8 MACs | |
| J2440 | Papaverine Hydrochloride | Excluded — varies by MAC | 6 of 8 MACs | |
| J2760 | Regitine | Excluded — varies by MAC | 1 of 8 MACs | |
| J2941 | Genotropin® Humatrope® Norditropin® Nutropin® Omnitrope Saizen Serostim Tev-Tropin DSC Zomacton Zorbtive | Excluded (all MACs) | All MACs | |
| J3030 | Imitrex® Alsuma DSC Imitrex STATdose Refill Imitrex STATdose System Onzetra Xsail Sumavel DosePro Zecuity DSC Zembrace SymTouch | Excluded (all MACs) | All MACs | |
| J3031 | Fremanezumab-vfrm AJOVY | Excluded (all MACs) | All MACs | |
| J3110 | Forteo® | Excluded — varies by MAC | 7 of 8 MACs | |
| J3357 | Stelara USTEKINUMAB, FOR SUBCUTANEOUS INJECTION, 1 MG | Excluded (all MACs) | All MACs | |
| J7999 | TriMix | Excluded — varies by MAC | 1 of 8 MACs | |
| J9213 | Peginterferon Alpha 2A Roferon A Pegasys Proclick | Excluded — varies by MAC | 7 of 8 MACs | |
| J9216 | Actimmune | Excluded (all MACs) | All MACs | |
| J9218 | Lupron® Eligard® | Excluded (all MACs) | All MACs | |
| Q0515 | INJECTION, SERMORELIN ACETATE, 1 MICROGRAM Geref Diagnostic | Excluded — varies by MAC | 6 of 8 MACs | |
| Q3027 | Injection, INJECTION, INTERFERON BETA-1A, 1 MCG FOR INTRAMUSCULAR USE Avonex | Excluded — varies by MAC | 6 of 8 MACs | |
| Q3028 | INJECTION, INTERFERON BETA-1A, 1 MCG FOR SUBCUTANEOUS USE Rebif | Excluded — varies by MAC | 6 of 8 MACs | |
| Q5098 | Inj ustekinumab-srlf, 1 mg | Route-dependent | 8 of 8 MACs | |
| Q5099 | Inj ustekinumab-stba, 1 mg | Route-dependent | 8 of 8 MACs | |
| Q5100 | Inj ustekinumab-kfce, 1 mg | Route-dependent | 8 of 8 MACs | |
| Q5137 | Wezlana (ustekinumab-auub) | Route-dependent | 7 of 8 MACs | |
| Q5140 | Injection, adalimumab-fkjp, biosimilar, 1 mg | Excluded (all MACs) | All MACs | |
| Q5141 | Injection, adalimumab-aaty, biosimilar, 1 mg | Excluded (all MACs) | All MACs | |
| Q5142 | Injection, adalimumab-ryvk biosimilar, 1 mg | Excluded (all MACs) | All MACs | |
| Q5143 | Injection, adalimumab-adbm, biosimilar, 1 mg | Excluded (all MACs) | All MACs | |
| Q5144 | Injection, adalimumab-aacf (idacio), biosimilar, 1 mg | Excluded (all MACs) | All MACs | |
| Q5145 | Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg | Excluded (all MACs) | All MACs | |
| Q9996 | Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg pyzchiva | Excluded (all MACs) | All MACs | |
| Q9998 | Injection, ustekinumab-aekn (selarsdi), 1 mg ustekinumab-aekn (selarsdi) | Route-dependent | 8 of 8 MACs | |
| Q9999 | Otulfi | Route-dependent | 8 of 8 MACs |
What is a self-administered drug (SAD) exclusion?
Medicare Part B covers drugs that are not usually self-administered by the patient (Social Security Act §1861(s)(2)(B)). CMS applies a >50%-of-patients test: if a drug is self-administered by more than half of Medicare patients who use it, it's excluded from Part B and falls under the Part D pharmacy benefit. For a buy-and-bill practice that means you generally can't bill Part B for it.
Why it varies by MAC
There is no single national SAD list. Each Medicare Administrative Contractor (MAC) publishes its own Self-Administered Drug Exclusion article and updates it at least annually, so the same drug can be excluded in one jurisdiction and payable in another. Always check the list for your MAC — pick your state above.
Route-dependent drugs & the JA / JB modifiers
Some drugs are route-dependent: covered under Part B intravenously but self-administered (excluded) subcutaneously. Use JA for intravenous and JB for subcutaneous, matching the route actually given.
Frequently asked questions
- What is a self-administered drug (SAD) under Medicare?
- A drug Medicare Part B does not cover because it is "usually self-administered by the patient" (Social Security Act §1861(s)(2)(B)). CMS applies a >50%-of-patients test. Each MAC publishes its own SAD exclusion list, so a drug can be Part B-excluded in one jurisdiction and not another; excluded drugs are typically covered instead under Part D.
- What are the JA and JB modifiers?
- For route-dependent drugs, JA indicates intravenous administration (often Part B covered) and JB indicates subcutaneous administration (often self-administered and excluded). Use the modifier matching the route given so the claim routes to the correct benefit.
Related references
Part B, Part D — or denied?
Confirm the benefit and the reimbursement before you administer. See the Medicare allowed amount and patient out-of-pocket for any specialty drug.
Try the cost estimator →Source & verification
- Source
- CMS Medicare Coverage Database — Self-Administered Drug Exclusion articles, one per MAC (data 2026-04-19).
- Page last reviewed by CareCost
- Jun 29, 2026; we re-verify against CMS quarterly and snapshot the lists to flag changes.
- Not advice
- General billing reference, not legal or billing advice. Verify against your MAC's current article before billing.
- Spotted an error?
- Email editorial@carecostestimate.com.