It means that it is excluded. The table referenced in Self-Administered Drug Exclusion List: Medical Policy Article A53021 lists drugs that are not covered by Medicare..

Acceptable evidentiary criteria indicates:

• A/B MACs (A), (B), and (HH+H), and DME MACs are only required to consider the following types of evidence: peer reviewed medical literature, standards of medical practice, evidence-based practice guidelines, FDA approved label, and package inserts. A/B MACs (A), (B), and (HHH), and DME MACs may also consider other evidence submitted by interested individuals or groups subject to their judgment.