Injections Requiring Prior Authorization

Transcription

1 At VIVA Health, we strive to keep our provider network informed of any changes. Most of you may currently obtain prior authorizations for administered injections. Below is a list of injection, infusion, and supply codes that require prior authorization IMMUNE GLOBULIN (IG), HUMAN, FOR INTRAMUSCULAR USE IMMUNE GLOBULIN (IGIV), HUMAN, FOR INTRAVENOUS USE BOTULINUM ANTITOXIN, EQUINE, ANY ROUTE BOTULISM IMMUNE GLOBULIN, HUMAN, FOR INTRAVENOUS USE CYTOMEGALOVIRUS IMMUNE GLOBULIN (CMV IGIV), HUMAN, FOR INTRAVENOUS USE UNLISTED IMMUNE GLOBULIN A9606 RADIUM RA 223 DICHLORIDE, THERAPEUTIC, PER MICROCURIE C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS INJECTION, ABATACEPT, 10 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE J0129 DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) J0135 INJECTION, ADALIMUMAB, 20 MG J0178 INJECTION, AFLIBERCEPT, 1 MG J0180 INJECTION, AGALSIDASE BETA, 1 MG J0202 INJECTION, ALEMTUZUMAB, 1 MG J0205 INJECTION, ALGLUCERASE, PER 10 UNITS J0215 INJECTION, ALEFACEPT, 0.5 MG J0220 INJECTION, ALGLUCOSIDASE ALFA, 10 MG, NOT OTHERWISE SPECIFIED J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), NOT OTHERWISE SPECIFIED, 10 MG J0257 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 MG J0364 INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG J0475 INJECTION, BACLOFEN, 10 MG J0476 INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL J0490 INJECTION, BELIMUMAB, 10 MG J0570 BUPRENORPHINE IMPLANT, 74.2 MG J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNITS J0588 INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT J0597 INJECTION, C 1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS J0598 INJECTION, C 1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS J0638 INJECTION, CANAKINUMAB, 1 MG J0717 J0775 J0800 J0850 J0881 J0882 J0885 J0887 J0888 J0894 J0895 J0897 J1260 J1290 J1300 J1322 J1324 J1325 J1438 INJECTION, CERTOLIZUMAB PEGOL, 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG INJECTION, CORTICOTROPIN, UP TO 40 UNITS INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON ESRD USE) INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS) INJECTION, EPOETIN ALFA, (FOR NON ESRD USE), 1000 UNITS INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR ESRD ON DIALYSIS) INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR NON ESRD USE) INJECTION, DECITABINE, 1 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DENOSUMAB, 1 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, ECALLANTIDE, 1 MG INJECTION, ECULIZUMAB, 10 MG INJECTION, ELOSULFASE ALFA, 1 MG INJECTION, ENFUVIRTIDE, 1 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Page 1 of 7

2 J1439 J1442 J1447 J1453 J1458 J1459 J1460 J1556 J1559 J1560 J1561 J1562 J1566 J1568 J1569 J1571 J1572 J1573 J1575 J1595 J1602 J1626 J1645 J1650 J1652 J1655 J1675 J1725 J1740 J1743 J1745 J1786 J1826 J1830 J1835 J1930 J1931 J1950 J2170 J2182 J2278 J2315 J2323 J2353 J2355 J2357 J2430 J2469 J2503 J2504 J2505 J2507 J2562 INJECTION, FERRIC CARBOXYMALTOSE, 1 MG INJECTION, FILGRASTIM (G CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM INJECTION, TBO FILGRASTIM, 1 MICROGRAM INJECTION, FOSAPREPITANT, 1 MG INJECTION, GALSULFASE, 1 MG INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON LYOPHILIZED (E.G., LIQUID), 500 MG INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC INJECTION, IMMUNE GLOBULIN, (GAMUNEX C/GAMMAKED), NON LYOPHILIZED (E.G., LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G., POWDER), NOT OTHERWISE SPECIFIED, 500 MG INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON LYOPHILIZED (E.G., LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON LYOPHILIZED, (E.G., LIQUID), 500 MG INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NON LYOPHILIZED (E.G., LIQUID), 500 MG INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVENOUS, 0.5 ML INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNE GLOBULIN INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, TINZAPARIN SODIUM, 1000 IU INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS INJECTION, HYDROXYPROGESTERONE CAPROATE, 1 MG INJECTION, IBANDRONATE SODIUM, 1 MG INJECTION, IDURSULFASE, 1 MG INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG INJECTION, IMIGLUCERASE, 10 UNITS INJECTION, INTERFERON BETA 1A, 30 MCG INJECTION, INTERFERON BETA 1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) INJECTION, ITRACONAZOLE, 50 MG INJECTION, LANREOTIDE, 1 MG INJECTION, LARONIDASE, 0.1 MG INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG INJECTION, MECASERMIN, 1 MG INJECTION, MEPOLIZUMAB, 1 MG INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, NALTREXONE, DEPOT FORM, 1 MG INJECTION, NATALIZUMAB, 1 MG INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG INJECTION, OPRELVEKIN, 5 MG INJECTION, OMALIZUMAB, 5 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PALONOSETRON HCL, 25 MCG INJECTION, PEGAPTANIB SODIUM, 0.3 MG INJECTION, PEGADEMASE BOVINE, 25 IU INJECTION, PEGFILGRASTIM, 6 MG INJECTION, PEGLOTICASE, 1 MG INJECTION, PLERIXAFOR, 1 MG Page 2 of 7

3 J2597 J2778 J2791 J2792 J2793 J2795 J2796 J2820 J2940 J2941 J2993 J3060 J3110 J3145 J3240 J3262 J3285 J3315 J3357 J3380 J3385 J3396 J3489 J3490 J3520 J3535 J3570 J3590 J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7197 J7198 J7199 J7200 J7201 J7300 J7307 J7308 J7310 J7311 J7312 J7313 J7316 INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, RANIBIZUMAB, 0.1 MG INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR OR INTRAVENOUS, 100 IU INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVENT DETERGENT, 100 IU INJECTION, RILONACEPT, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROMIPLOSTIM, 10 MICROGRAMS INJECTION, SARGRAMOSTIM (GM CSF), 50 MCG INJECTION, SOMATREM, 1 MG INJECTION, SOMATROPIN, 1 MG INJECTION, RETEPLASE, 18.1 MG INJECTION, TALIGLUCERACE ALFA, 10 UNITS INJECTION, TERIPARATIDE, 10 MCG INJECTION, TESTOSTERONE UNDECANOATE, 1 MG INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIAL INJECTION, TOCILIZUMAB, 1 MG INJECTION, TREPROSTINIL, 1 MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG USTEKINUMAB, FOR SUBCUTANEOUS INJECTION, 1 MG INJECTION, VEDOLIZUMAB, 1 MG INJECTION, VELAGLUCERASE ALFA, 100 UNITS INJECTION, VERTEPORFIN, 0.1 MG INJECTION, ZOLEDRONIC ACID, 1 MG UNCLASSIFIED DRUGS EDETATE DISODIUM, PER 150 MG DRUG ADMINISTERED THROUGH A METERED DOSE INHALER LAETRILE, AMYGDALIN, VITAMIN B17 UNCLASSIFIED BIOLOGICS INJECTION, FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 I.U. INJECTION, FACTOR XIII A SUBUNIT, (RECOMBINANT), PER IU INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (NOVOEIGHT), PER IU INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, 1 I.U. VWF:RCO INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U. INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN), PER FACTOR VIII I.U. INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE P), PER IU VWF:RCO FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISE SPECIFIED FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON RECOMBINANT) PER I.U. FACTOR IX, COMPLEX, PER I.U. INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER IU, NOT OTHERWISE SPECIFIED ANTITHROMBIN III (HUMAN), PER I.U. ANTI INHIBITOR, PER I.U. HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), RIXUBIS, PER IU INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINANT), ALPROLIX, 1 I.U. INTRAUTERINE COPPER CONTRACEPTIVE ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SINGLE UNIT DOSAGE FORM (354 MG) GANCICLOVIR, 4.5 MG, LONG ACTING IMPLANT FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MG INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT, 0.01 MG INJECTION, OCRIPLASMIN, MG Page 3 of 7

4 J7321 J7323 J7324 J7325 J7327 J7330 J7336 J7509 J7510 J7516 J7605 J7606 J7607 J7609 J7610 J7615 J7620 J7622 J7624 J7626 J7627 J7628 J7629 J7631 J7633 J7634 J7635 J7636 J7637 J7638 J7639 J7640 J7641 HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA ARTICULAR INJECTION, PER DOSE HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA ARTICULAR INJECTION, PER DOSE HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA ARTICULAR INJECTION, PER DOSE HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC ONE, FOR INTRA ARTICULAR INJECTION, 1 MG HYALURONAN OR DERIVATIVE, MONOVISC, FOR INTRA ARTICULAR INJECTION, PER DOSE AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER METHYLPREDNISOLONE ORAL, PER 4 MG PREDNISOLONE ORAL, PER 5 MG CYCLOSPORIN, PARENTERAL, 250 MG ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE BUDESONIDE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE CROMOLYN SODIUM, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS BUDESONIDE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE DORNASE ALFA, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 12 MICROGRAMS FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, PER MILLIGRAM Page 4 of 7

5 J7642 J7643 J7644 J7645 J7647 J7648 J7649 J7657 J7667 J7674 J7676 J7685 J7686 J7699 J7799 J7999 J8499 J8501 J8520 J8521 J8562 J8565 J8597 J8650 J8700 J8705 J9015 J9017 J9020 J9025 J9033 J9035 J9041 J9043 J9045 J9047 J9055 J9070 J9145 J9155 J9171 J9179 J9201 J9202 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, ISOETHARINE HCL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, ISOETHARINE HCL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATED FORM, PER 10 MILLIGRAMS METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION THROUGH A NEBULIZER, PER 1 MG PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MILLIGRAMS TREPROSTINIL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MG NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS APREPITANT, ORAL, 5 MG CAPECITABINE, ORAL, 150 MG CAPECITABINE, ORAL, 500 MG FLUDARABINE PHOSPHATE, ORAL, 10 MG GEFITINIB, ORAL, 250 MG ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED NABILONE, ORAL, 1 MG TEMOZOLOMIDE, ORAL, 5 MG TOPOTECAN, ORAL, 0.25 MG INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ASPARAGINASE, NOT OTHERWISE SPECIFIED, 10,000 UNITS INJECTION, AZACITIDINE, 1 MG INJECTION, BENDAMUSTINE HCL (TREANDA), 1 MG INJECTION, BEVACIZUMAB, 10 MG INJECTION, BORTEZOMIB, 0.1 MG INJECTION, CABAZITAXEL, 1 MG INJECTION, CARBOPLATIN, 50 MG INJECTION, CARFILZOMIB, 1 MG INJECTION, CETUXIMAB, 10 MG CYCLOPHOSPHAMIDE, 100 MG INJECTION, DARATUMUMAB, 10 MG INJECTION, DEGARELIX, 1 MG INJECTION, DOCETAXEL, 1 MG INJECTION, ERIBULIN MESYLATE, 0.1 MG INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG GOSERELIN ACETATE IMPLANT, PER 3.6 MG Page 5 of 7

6 J9206 J9207 J9213 J9214 J9216 J9217 J9218 J9225 J9226 J9228 J9262 J9263 J9264 J9266 J9267 J9271 J9293 J9299 J9301 J9303 J9305 J9306 J9307 J9308 J9310 J9315 J9328 J9330 J9351 J9354 J9355 J9357 J9371 J9395 J9400 J9999 Q0515 Q2026 Q2028 Q2043 Q2049 Q2050 Q4081 Q4082 Q5101 Q5102 S0088 S0104 S0117 S0122 S0126 S0128 S0132 S0142 INJECTION, IRINOTECAN, 20 MG INJECTION, IXABEPILONE, 1 MG INJECTION, INTERFERON, ALFA 2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA 2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, GAMMA 1 B, 3 MILLION UNITS LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE, PER 1 MG HISTRELIN IMPLANT (VANTAS), 50 MG HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG INJECTION, IPILIMUMAB, 1 MG INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, PACLITAXEL PROTEIN BOUND PARTICLES, 1 MG INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL INJECTION, PACLITAXEL, 1 MG INJECTION, PEMBROLIZUMAB, 1 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, NIVOLUMAB, 1 MG INJECTION, OBINUTUZUMAB, 10 MG INJECTION, PANITUMUMAB, 10 MG INJECTION, PEMETREXED, 10 MG INJECTION, PERTUZUMAB, 1 MG INJECTION, PRALATREXATE, 1 MG INJECTION, RAMUCIRUMAB, 5 MG INJECTION, RITUXIMAB, 100 MG INJECTION, ROMIDEPSIN, 1 MG INJECTION, TEMOZOLOMIDE, 1 MG INJECTION, TEMSIROLIMUS, 1 MG INJECTION, TOPOTECAN, 0.1 MG INJECTION, ADO TRASTUZUMAB EMTANSINE, 1 MG INJECTION, TRASTUZUMAB, 10 MG INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG INJECTION, FULVESTRANT, 25 MG INJECTION, ZIV AFLIBERCEPT, 1 MG NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS INJECTION, SERMORELIN ACETATE, 1 MICROGRAM INJECTION, RADIESSE, 0.1 ML INJECTION, SCULPTRA, 0.5 MG SIPULEUCEL T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH PAP GM CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURES, PER INFUSION INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, IMPORTED LIPODOX, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWISE SPECIFIED, 10 MG INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS) DRUG OR BIOLOGICAL, NOT OTHERWISE CLASSIFIED, PART B DRUG COMPETITIVE ACQUISITION PROGRAM (CAP) INJECTION, FILGRASTIM (G CSF), BIOSIMILAR, 1 MICROGRAM INJECTION, INFLIXIMAB, BIOSIMILAR, 10 MG IMATINIB, 100 MG ZIDOVUDINE, ORAL, 100 MG TRETINOIN, TOPICAL, 5 GRAMS INJECTION, MENOTROPINS, 75 IU INJECTION, FOLLITROPIN ALFA, 75 IU INJECTION, FOLLITROPIN BETA, 75 IU INJECTION, GANIRELIX ACETATE, 250 MCG COLISTIMETHATE SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MG Page 6 of 7

7 S0145 S0189 INJECTION, PEGYLATED INTERFERON ALFA 2A, 180 MCG PER ML TESTOSTERONE PELLET, 75 MG Page 7 of 7