Provider Bulletin April 2017

Transcription

1 Provider Bulletin April 2017 A bulletin for the Molina Healthcare of New York, Inc. Network (Formerly Total Care, A Today s Options of New York Health Plan) Questions? Call Provider Services (877) Monday through Thursday 8:00 a.m.-5:00 p.m. Friday 9:00 a.m.-5:00 p.m. Molina Healthcare Provider Update - NDC Requirement When billing for physician-administered drugs in a non-inpatient setting, New York State Dept. of Health is requiring National Drug Code (NDC) be included when HCPCS Codes (J0000-J9999) are reported without a UD modifier. This NDC requirement also includes BETOS Codes (/) for physician-administered drugs in a non-inpatient setting and reported without a UD modifier. The and codes represent Chemotherapy and Other Drugs that would fall into the categorization of Physician Administered Drugs. Per the attached list from NYS, these are A-Codes, C-Codes, G-Codes, and Q-Codes. Below is a summary of the system edit modification to include the BETOS codes that will be applied to our claims processing as of 4/1/17. If a J-Code (HCPCS) is submitted for a physician-administered drug in a non-inpatient setting and the Procedure Code Modifier is not UD, a valid NDC must be included. A procedure code is considered a J-Code when; 1) HCPCS procedure codes equal J0000 through J9999 OR 2) BETOS codes (from HCPCS file) equal and

2 HCPC LONG DESCRIPTION SHORT DESCRIPTION BETOS C9021 Injection, obinutuzumab, 10 Injection, obinutuzumab C9025 Injection, ramucirumab, 5 Injection, ramucirumab C9131 Injection, ado-trastuzumab In ado-trastuzumab emtansine emtansine, 1 C9287 Injection, brentuximab Inj, brentuximab vedotin vedotin, 1 C9289 (i.u.) Inj, erwinia chrysanthemi C9292 Injection, pertuzumab, 10 Injection, pertuzumab C9295 Injection, carfilzomib, 1 Injection, carfilzomib C9296 Injection, ziv-aflibercept, 1 Injection, ziv-aflibercept C9297 Injection, omacetaxine Omacetaxine mepesuccinate mepesuccinate, 0.01 C9442 Injection, belinostat, 10 Injection, belinostat C9449 Injection, blinatumomab, 1 Inj, blinatumomab mcg C9453 Injection, nivolumab, 1 Injection, nivolumab C9455 Injection, siltuximab, 10 Injection, siltuximab J0207 Injection, amifostine, 500 Amifostine J1260 Injection, dolasetron mesylate, Dolasetron mesylate 10 J8498 Antiemetic drug, Antiemetic rectal/supp nos rectal/suppository, not otherwise specified J8510 Busulfan; oral, 2 Oral busulfan J8520 Capecitabine, oral, 150 Capecitabine, oral, 150 J8521 Capecitabine, oral, 500 Capecitabine, oral, 500 J8530 Cyclophosphamide; oral, 25 Cyclophosphamide oral 25 J8560 Etoposide; oral, 50 Etoposide oral 50 J8562 Fludarabine phosphate, oral, Oral fludarabine phosphate 10 J8597 Antiemetic drug, oral, not Antiemetic drug oral nos otherwise specified J8600 Melphalan; oral, 2 Melphalan oral 2 J8610 Methotrexate; oral, 2.5 Methotrexate oral 2.5 J8700 Temozolomide, oral, 5 Temozolomide J8705 Topotecan, oral, 0.25 Topotecan oral J8999 Prescription drug, oral, Oral prescription drug chemo chemotherapeutic, nos J9000 Injection, doxorubicin Doxorubicin hcl injection hydrochloride, 10 J9002 Injection, doxorubicin Doxil injection hydrochloride, liposomal, doxil, 10 J9015 Injection, aldesleukin, per Aldesleukin injection single use vial J9017 Injection, arsenic trioxide, 1 Arsenic trioxide injection

3 J9019 Injection, asparaginase Erwinaze injection (erwinaze), 1,000 iu J9020 Injection, asparaginase, not Asparaginase, nos otherwise specified, 10,000 units J9025 Injection, azacitidine, 1 Azacitidine injection J9031 Bcg (intravesical) per Bcg live intravesical vac instillation J9032 Injection, belinostat, 10 Injection, belinostat, 10 J9033 Injection, bendamustine hcl, 1 Bendamustine injection J9039 Injection, blinatumomab, 1 Injection, blinatumomab microgram J9040 Injection, bleomycin sulfate, Bleomycin sulfate injection 15 units J9042 Injection, brentuximab Brentuximab vedotin inj vedotin, 1 J9043 Injection, cabazitaxel, 1 Cabazitaxel injection J9045 Injection, carboplatin, 50 Carboplatin injection J9047 Injection, carfilzomib, 1 Injection, carfilzomib, 1 J9050 Injection, carmustine, 100 Carmustine injection J9060 Injection, cisplatin, powder or Cisplatin 10 injection solution, 10 J9065 Injection, cladribine, per 1 Inj cladribine per 1 J9070 Cyclophosphamide, 100 Cyclophosphamide 100 inj J9100 Injection, cytarabine, 100 Cytarabine hcl 100 inj J9120 Injection, dactinomycin, 0.5 Dactinomycin injection J9130 Dacarbazine, 100 Dacarbazine 100 inj J9150 Injection, daunorubicin, 10 Daunorubicin injection J9151 Injection, daunorubicin citrate, Daunorubicin citrate inj liposomal formulation, 10 J9165 Injection, diethylstilbestrol Diethylstilbestrol injection diphosphate, 250 J9179 Injection, eribulin mesylate, Eribulin mesylate injection 0.1 J9181 Injection, etoposide, 10 Etoposide injection J9185 Injection, fludarabine Fludarabine phosphate inj phosphate, 50 J9190 Injection, fluorouracil, 500 Fluorouracil injection J9200 Injection, floxuridine, 500 Floxuridine injection J9201 Injection, gemcitabine Gemcitabine hcl injection hydrochloride, 200 J9202 Goserelin acetate implant, per Goserelin acetate implant 3.6 J9206 Injection, irinotecan, 20 Irinotecan injection J9207 Injection, ixabepilone, 1 Ixabepilone injection J9208 Injection, ifosfamide, 1 gram Ifosfamide injection J9209 Injection, mesna, 200 Mesna injection J9211 Injection, idarubicin hydrochloride, 5 Idarubicin hcl injection

4 J9213 Injection, interferon, alfa-2a, Interferon alfa-2a inj recombinant, 3 million units J9214 Injection, interferon, alfa-2b, Interferon alfa-2b inj recombinant, 1 million units J9215 Injection, interferon, alfa-n3, Interferon alfa-n3 inj (human leukocyte derived), 250,000 iu J9216 Injection, interferon, gamma Interferon gamma 1-b inj 1-b, 3 million units J9217 Leuprolide acetate (for depot Leuprolide acetate suspnsion suspension), 7.5 J9218 Leuprolide acetate, per 1 Leuprolide acetate injeciton J9219 Leuprolide acetate implant, 65 Leuprolide acetate implant J9225 Histrelin implant (vantas), 50 Vantas implant J9226 Histrelin implant (supprelin la), Supprelin la implant 50 J9228 Injection, ipilimumab, 1 Ipilimumab injection J9230 Injection, mechlorethamine Mechlorethamine hcl inj hydrochloride, (nitrogen mustard), 10 J9245 Injection, melphalan Inj melphalan hydrochl 50 hydrochloride, 50 J9250 Methotrexate sodium, 5 Methotrexate sodium inj J9260 Methotrexate sodium, 50 Methotrexate sodium inj J9262 Injection, omacetaxine Inj, omacetaxine mep, 0.01 mepesuccinate, 0.01 J9263 Injection, oxaliplatin, 0.5 Oxaliplatin J9265 Injection, paclitaxel, 30 Paclitaxel injection J9266 Injection, pegaspargase, per Pegaspargase injection single dose vial J9267 Injection, paclitaxel, 1 Paclitaxel injection J9268 Injection, pentostatin, 10 Pentostatin injection J9270 Injection, plicamycin, 2.5 Plicamycin (mithramycin) inj J9271 Injection, pembrolizumab, 1 Inj pembrolizumab J9280 Injection, mitomycin, 5 Mitomycin injection J9293 Injection, mitoxantrone Mitoxantrone hydrochl / 5 hydrochloride, per 5 J9299 Injection, nivolumab, 1 Injection, nivolumab J9300 Injection, gemtuzumab Gemtuzumab ozogamicin inj ozogamicin, 5 J9301 Injection, obinutuzumab, 10 Obinutuzumab inj J9302 Injection, ofatumumab, 10 Ofatumumab injection J9303 Injection, panitumumab, 10 Panitumumab injection J9306 Injection, pertuzumab, 1 Injection, pertuzumab, 1 J9308 Injection, ramucirumab, 5 Injection, ramucirumab J9310 Injection, rituximab, 100 Rituximab injection

5 J9315 Injection, romidepsin, 1 Romidepsin injection J9320 Injection, streptozocin, 1 gram Streptozocin injection J9328 Injection, temozolomide, 1 Temozolomide injection J9330 Injection, temsirolimus, 1 Temsirolimus injection J9340 Injection, thiotepa, 15 Thiotepa injection J9351 Injection, topotecan, 0.1 Topotecan injection J9354 Injection, ado-trastuzumab Inj, ado-trastuzumab emt 1 emtansine, 1 J9360 Injection, vinblastine sulfate, 1 Vinblastine sulfate inj J9370 Vincristine sulfate, 1 Vincristine sulfate 1 inj J9371 Injection, vincristine sulfate Inj, vincristine sul lip 1 liposome, 1 J9390 Injection, vinorelbine tartrate, Vinorelbine tartrate inj 10 J9600 Injection, porfimer sodium, 75 Porfimer sodium injection J9999 Not otherwise classified, Chemotherapy drug antineoplastic drugs Q0083 subcutaneous, intramuscular, Chemo by other than infusion push), per visit Q0084 Chemotherapy administration Chemotherapy by infusion by infusion technique only, per visit Q0085 Chemotherapy administration Chemo by both infusion and o by both infusion technique and other techique(s) (e.g., subcutaneous, intramuscular, push), per visit Q0161 emetic, for use as a complete Chlorpromazine hcl 5 oral therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage Q0162 a complete therapeutic Ondansetron oral substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q0163 anti-emetic, for use as a Diphenhydramine hcl 50 complete therapeutic substitute for an iv antiemetic at time of chemotherapy treatment not to exceed a 48 hour dosage Q0164 emetic, for use as a complete Prochlorperazine maleate 5 therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage Q0165 emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of Prochlorperazine maleate10

6 chemotherapy treatment, not to exceed a 48 hour dosage Q0166 Q0167 Q0168 Q0169 Q0170 Q0171 Q0172 Q0173 Q0174 Q0175 emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Granisetron hcl 1 oral Dronabinol 2.5 oral Dronabinol 5 oral Promethazine hcl 12.5 oral Promethazine hcl 25 oral Chlorpromazine hcl 10 oral Chlorpromazine hcl 25 oral Trimethobenzamide hcl 250 Thiethylperazine maleate10 Perphenazine 4 oral

7 Q0176 a complete therapeutic Perphenazine 8 oral substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q0177 for use as a complete Hydroxyzine pamoate 25 therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q0178 for use as a complete Hydroxyzine pamoate 50 therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q0180 for use as a complete Dolasetron mesylate oral therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen Q0181 use as a complete therapeutic Unspecified oral anti-emetic substitute for a iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q2017 Injection, teniposide, 50 Teniposide, 50 Q2048 Injection, doxorubicin Doxil injection hydrochloride, liposomal, doxil, 10 Q2049 Injection, doxorubicin Imported lipodox inj hydrochloride, liposomal, imported lipodox, 10 Q2050 Doxorubicin inj 10 A4218 Sterile saline or water, Sterile saline or water metered dose dispenser, 10 ml A9150 Non-prescription drugs Misc/exper non-prescript dru C9022 Injection, elosulfase alfa, 1 Injection, elosulfase alfa C9023 Injection, testosterone Inj testosterone undecanoate undecanoate, 1 C9026 Injection, vedolizumab, 1 Injection, vedolizumab C9027 Injection, pembrolizumab, 1 Injection, pembrolizumab C9113 Injection, pantoprazole Inj pantoprazole sodium, via sodium, per vial C9121 Injection, argatroban, per 5 Injection, argatroban C9130 Injection, immune globulin Injection, ivig bivigam (bivigam), 500 C9132 activity Kcentra, per i.u.

8 C9133 Factor ix (antihemophilic Factor ix recombinant factor, recombinant), rixubis, per i.u. C9134 Factor xiii (antihemophilic Factor xiii a-subunit recomb factor, recombinant), tretten, per 10 i.u. C9135 Factor ix (antihemophilic Factor ix (alprolix) factor, recombinant), alprolix, per i.u. C9136 Injection, factor viii, fc fusion Factor viii (eloctate) protein, (recombinant), per i.u. C9248 Injection, clevidipine butyrate, Inj, clevidipine butyrate 1 C9250 ml Artiss fibrin sealant C9254 Injection, lacosamide, 1 Injection, lacosamide C9257 Injection, bevacizumab, 0.25 Bevacizumab injection C9275 Injection, hexaminolevulinate Hexaminolevulinate hcl hydrochloride, 100, per study dose C9279 Injection, ibuprofen, 100 Injection, ibuprofen C9285 Lidocaine 70 /tetracaine 70 Patch, lidocaine/tetracaine, per patch C9286 Injection, belatacept, 1 Injection, belatacept C9288 Injection, centruroides Inj, centruroides (scorpion) (scorpion) immune f(ab)2 (equine), 1 vial C9290 Injection, bupivacaine Inj, bupivacaine liposome liposome, 1 C9291 Injection, aflibercept, 2 vial Injection, aflibercept C9293 Injection, glucarpidase, 10 Injection, glucarpidase units C9294 Injection, taliglucerase alfa, 10 Inj, taliglucerase alfa units C9298 Injection, ocriplasmin, Injection, ocriplasmin C9349 Puraply, and puraply Puraply, puraply antimic antimicrobial, any type, per square C9366 Epifix, per square Epifix wound cover C9367 Skin substitute, endoform Endoform dermal template dermal template, per square C9368 Grafix core, per square Grafix core C9369 Grafix prime, per square Grafix prime C9399 Unclassified drugs or Unclassified drugs or biolog biologicals C9441 Injection, ferric Inj, ferric carboxymaltose carboxymaltose, 1 C9443 Injection, dalbavancin, 10 Injection, dalbavancin

9 C9444 Injection, oritavancin, 10 Injection, oritavancin C9445 Injection, c-1 esterase C-1 esterase, ruconest inhibitor (recombinant), ruconest, 10 units C9446 Injection, tedizolid phosphate, Inj, tedizolid phosphate 1 C9447 Injection, phenylephrine and Inj, phenylephrine ketorolac ketorolac, 4 ml vial C9448 Netupitant 300 and Oral netupitant palonosetron palonosetron 0.5, oral C9450 Injection, fluocinolone Fluocinolone acetonide implt acetonide intravitreal implant, 0.01 C9451 Injection, peramivir, 1 Injection, peramivir C9452 Injection, ceftolozane 50 Inj, ceftolozane/tazobactam and tazobactam 25 C9454 Injection, pasireotide long Inj, pasireotide long acting acting, 1 C9456 Injection, isavuconazonium Inj, isavuconazonium sulfate sulfate, 1 C9457 Injection, sulfur hexafluoride Lumason contrast agent lipid microsphere, per ml C9458 Florbetaben f18, diagnostic, Florbetaben f18 per study dose, up to 8.1 millicuries C9459 Flutemetamol f18, diagnostic, Flutemetamol f18 per study dose, up to 5 millicuries C9460 Injection, cangrelor, 1 Injection, cangrelor C9497 Loxapine, inhalation powder, Loxapine, inhalation powder 10 C9737 (e.g., magnetic band) Lap esoph augmentation G0259 Injection procedure for Inject for sacroiliac joint sacroiliac joint; arthrograpy G0260 Injection procedure for Inj for sacroiliac jt anesth sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography G9017 approved demonstration Amantadine hcl 100 oral project) G9018 Zanamivir, inhalation powder, Zanamivir,inhalation pwd 10m administered through inhaler, per 10 (for use in a medicare-approved demonstration project) G9019 demonstration project) Oseltamivir phosphate 75 G9020 G9033 approved demonstration project) approved demonstration project) Rimantadine hcl 100 oral Amantadine hcl oral brand

10 G9034 Zanamivir, inhalation powder, Zanamivir, inh pwdr, brand administered through inhaler, brand, per 10 (for use in a medicare-approved demonstration project) G9035 approved demonstration Oseltamivir phosp, brand project) G9036 approved demonstration Rimantadine hcl, brand project) J0120 Injection, tetracycline, up to Tetracyclin injection 250 J0129 administered under the direct Abatacept injection supervision of a physician, not for use when drug is self administered) J0130 Injection abciximab, 10 Abciximab injection J0131 Injection, acetaminophen, 10 Acetaminophen injection J0132 Injection, acetylcysteine, 100 Acetylcysteine injection J0133 Injection, acyclovir, 5 Acyclovir injection J0135 Injection, adalimumab, 20 Adalimumab injection J0150 Injection, adenosine for Injection adenosine 6 therapeutic use, 6 (not to be used to report any adenosine phosphate compounds, instead use a9270) J0151 Injection, adenosine for Inj adenosine diag 1 diagnostic use, 1 (not to be used to report any adenosine phosphate compounds, instead use a9270) J0152 Injection, adenosine for Adenosine injection diagnostic use, 30 (not to be used to report any adenosine phosphate compounds; instead use a9270) J0153 phosphate compounds) Adenosine inj 1 J0171 Injection, adrenalin, Adrenalin epinephrine inject epinephrine, 0.1 J0178 Injection, aflibercept, 1 Aflibercept injection J0180 Injection, agalsidase beta, 1 Agalsidase beta injection J0190 Injection, biperiden lactate, Inj biperiden lactate/5 per 5 J0200 Injection, alatrofloxacin Alatrofloxacin mesylate mesylate, 100 J0202 Injection, alemtuzumab, 1 Injection, alemtuzumab J0205 Injection, alglucerase, per 10 units Alglucerase injection

11 J0210 Injection, methyldopate hcl, up Methyldopate hcl injection to 250 J0215 Injection, alefacept, 0.5 Alefacept J0220 Injection, alglucosidase alfa, Alglucosidase alfa injection 10, not otherwise specified J0221 Injection, alglucosidase alfa, Lumizyme injection (lumizyme), 10 J0256 Alpha 1 proteinase inhibitor J0257 Injection, alpha 1 proteinase Glassia injection inhibitor (human), (glassia), 10 J0270 drug administered under the Alprostadil for injection direct supervision of a physician, not for use when drug is self administered) J0275 drug administered under the Alprostadil urethral suppos direct supervision of a physician, not for use when drug is self administered) J0278 Injection, amikacin sulfate, Amikacin sulfate injection 100 J0280 Injection, aminophyllin, up to Aminophyllin 250 inj 250 J0282 Injection, amiodarone Amiodarone hcl hydrochloride, 30 J0285 Injection, amphotericin b, 50 Amphotericin b J0287 Injection, amphotericin b lipid Amphotericin b lipid complex complex, 10 J0288 Injection, amphotericin b Ampho b cholesteryl sulfate cholesteryl sulfate complex, 10 J0289 Injection, amphotericin b Amphotericin b liposome inj liposome, 10 J0290 Injection, ampicillin sodium, Ampicillin 500 inj 500 J0295 Injection, ampicillin Ampicillin sodium per 1.5 gm sodium/sulbactam sodium, per 1.5 gm J0300 Injection, amobarbital, up to Amobarbital 125 inj 125 J0330 Injection, succinylcholine Succinycholine chloride inj chloride, up to 20 J0348 Injection, anidulafungin, 1 Anidulafungin injection J0350 Injection, anistreplase, per 30 Injection anistreplase 30 u units J0360 Injection, hydralazine hcl, up Hydralazine hcl injection to 20 J0364 Injection, apomorphine Apomorphine hydrochloride hydrochloride, 1 J0365 Injection, aprotonin, 10,000 kiu Aprotonin, 10,000 kiu

12 J0380 Injection, metaraminol Inj metaraminol bitartrate bitartrate, per 10 J0390 Injection, chloroquine Chloroquine injection hydrochloride, up to 250 J0395 Injection, arbutamine hcl, 1 Arbutamine hcl injection J0400 Injection, aripiprazole, Aripiprazole injection intramuscular, 0.25 J0401 Injection, aripiprazole, Inj aripiprazole ext rel 1 extended release, 1 J0456 Injection, azithromycin, 500 Azithromycin J0461 Injection, atropine sulfate, Atropine sulfate injection 0.01 J0470 Injection, dimercaprol, per 100 Dimecaprol injection J0475 Injection, baclofen, 10 Baclofen 10 injection J0476 Injection, baclofen, 50 mcg for Baclofen intrathecal trial intrathecal trial J0480 Injection, basiliximab, 20 Basiliximab J0485 Injection, belatacept, 1 Belatacept injection J0490 Injection, belimumab, 10 Belimumab injection J0500 Injection, dicyclomine hcl, up Dicyclomine injection to 20 J0515 Injection, benztropine Inj benztropine mesylate mesylate, per 1 J0520 Injection, bethanechol Bethanechol chloride inject chloride, myotonachol or urecholine, up to 5 J0558 Injection, penicillin g Peng benzathine/procaine inj benzathine and penicillin g procaine, 100,000 units J0561 Injection, penicillin g Penicillin g benzathine inj benzathine, 100,000 units J0571 Buprenorphine/naloxone, oral, Buprenorphine oral 1 less than or equal to 3 buprenorphine J0572 Buprenorphine/naloxone, oral, Bupren/nal up to 3 bupreno less than or equal to 3 buprenorphine J to 6 Bupren/nal 3.1 to 6 bupren J buprenorphine Bupren/nal 6.1 to 10 bupre J0575 Buprenorphine/naloxone, oral, Bupren/nal over 10 bupreno greater than 10 buprenorphine J0583 Injection, bivalirudin, 1 Bivalirudin J0585 Injection, onabotulinumtoxina, Injection,onabotulinumtoxina 1 unit J0586 Injection, abobotulinumtoxina, Abobotulinumtoxina 5 units J0587 Injection, rimabotulinumtoxinb, 100 units Inj, rimabotulinumtoxinb

13 J0588 Injection, incobotulinumtoxin Incobotulinumtoxin a a, 1 unit J0592 Injection, buprenorphine Buprenorphine hydrochloride hydrochloride, 0.1 J0594 injection, busulfan, 1 Busulfan injection J0595 Injection, butorphanol tartrate, Butorphanol tartrate 1 1 J0596 Injection, c1 esterase inhibitor Injection, ruconest (recombinant), ruconest, 10 units J0597 Injection, c-1 esterase C-1 esterase, berinert inhibitor (human), berinert, 10 units J0598 Injection, c-1 esterase C-1 esterase, cinryze inhibitor (human), cinryze, 10 units J0600 Injection, edetate calcium Edetate calcium disodium inj disodium, up to 1000 J0610 Injection, calcium gluconate, Calcium gluconate injection per 10 ml J0620 Injection, calcium Calcium glycer & lact/10 ml glycerophosphate and calcium lactate, per 10 ml J0630 Injection, calcitonin salmon, Calcitonin salmon injection up to 400 units J0636 Injection, calcitriol, 0.1 mcg Inj calcitriol per 0.1 mcg J0637 Injection, caspofungin acetate, Caspofungin acetate 5 J0638 Injection, canakinumab, 1 Canakinumab injection J0640 Injection, leucovorin calcium, Leucovorin calcium injection per 50 J0641 Injection, levoleucovorin Levoleucovorin injection calcium, 0.5 J0670 Injection, mepivacaine Inj mepivacaine hcl/10 ml hydrochloride, per 10 ml J0690 Injection, cefazolin sodium, Cefazolin sodium injection 500 J0692 Injection, cefepime Cefepime hcl for injection hydrochloride, 500 J0694 Injection, cefoxitin sodium, 1 Cefoxitin sodium injection gm J0695 Injection, ceftolozane 50 Inj ceftolozane tazobactam and tazobactam 25 J0696 Injection, ceftriaxone sodium, Ceftriaxone sodium injection per 250 J0697 Injection, sterile cefuroxime Sterile cefuroxime injection sodium, per 750 J0698 Injection, cefotaxime sodium, Cefotaxime sodium injection per gm J0702 phosphate 3 Betamethasone acet&sod phosp J0706 Injection, caffeine citrate, 5 Caffeine citrate injection

14 J0710 Injection, cephapirin sodium, Cephapirin sodium injection up to 1 gm J0712 Injection, ceftaroline fosamil, Ceftaroline fosamil inj 10 J0713 Injection, ceftazidime, per 500 Inj ceftazidime per 500 J0714 Injection, ceftazidime and Ceftazidime and avibactam avibactam, 0.5 g/0.125 g J0715 Injection, ceftizoxime sodium, Ceftizoxime sodium / 500 per 500 J0716 Injection, centruroides Centruroides immune f(ab) immune f(ab)2, up to 120 milligrams J0717 drug administered under the Certolizumab pegol inj 1 direct supervision of a physician, not for use when drug is self administered) J0718 Injection, certolizumab pegol, Certolizumab pegol inj 1 J0720 Injection, chloramphenicol Chloramphenicol sodium injec sodium succinate, up to 1 gm J0725 Injection, chorionic Chorionic gonadotropin/1000u gonadotropin, per 1,000 usp units J0735 Injection, clonidine Clonidine hydrochloride hydrochloride, 1 J0740 Injection, cidofovir, 375 Cidofovir injection J0743 Injection, cilastatin sodium; Cilastatin sodium injection imipenem, per 250 J0744 Injection, ciprofloxacin for Ciprofloxacin iv intravenous infusion, 200 J0745 Injection, codeine phosphate, Inj codeine phosphate /30 per 30 J0760 Injection, colchicine, per 1 Colchicine injection J0770 Injection, colistimethate Colistimethate sodium inj sodium, up to 150 J0775 Injection, collagenase, Collagenase, clost hist inj clostridium histolyticum, 0.01 J0780 Injection, prochlorperazine, up Prochlorperazine injection to 10 J0795 Injection, corticorelin ovine Corticorelin ovine triflutal triflutate, 1 microgram J0800 Injection, corticotropin, up to Corticotropin injection 40 units J0833 Injection, cosyntropin, not Cosyntropin injection nos otherwise specified, 0.25 J0834 Injection, cosyntropin Cosyntropin cortrosyn inj (cortrosyn), 0.25 J0840 Injection, crotalidae polyvalent immune fab (ovine), up to 1 Crotalidae poly immune fab

15 gram J0850 Injection, cytomegalovirus Cytomegalovirus imm iv /vial immune globulin intravenous (human), per vial J0875 Injection, dalbavancin, 5 Injection, dalbavancin J0878 Injection, daptomycin, 1 Daptomycin injection J0881 Injection, darbepoetin alfa, 1 Darbepoetin alfa, non-esrd microgram (non-esrd use) J0882 Injection, darbepoetin alfa, 1 Darbepoetin alfa, esrd use microgram (for esrd on dialysis) J0885 Injection, epoetin alfa, (for Epoetin alfa, non-esrd non-esrd use), 1000 units J0886 Injection, epoetin alfa, 1000 Epoetin alfa 1000 units esrd units (for esrd on dialysis) J0887 Injection, epoetin beta, 1 Epoetin beta esrd use microgram, (for esrd on dialysis) J0888 Injection, epoetin beta, 1 Epoetin beta non esrd microgram, (for non esrd use) J0890 Injection, peginesatide, 0.1 Peginesatide injection (for esrd on dialysis) J0894 Injection, decitabine, 1 Decitabine injection J0895 Injection, deferoxamine Deferoxamine mesylate inj mesylate, 500 J0897 Injection, denosumab, 1 Denosumab injection J0900 Injection, testosterone Testosterone enanthate inj enanthate and estradiol valerate, up to 1 cc J0945 Injection, brompheniramine Brompheniramine maleate inj maleate, per 10 J1000 Injection, depo-estradiol Depo-estradiol cypionate inj cypionate, up to 5 J1020 Injection, methylprednisolone Methylprednisolone 20 inj acetate, 20 J1030 Injection, methylprednisolone Methylprednisolone 40 inj acetate, 40 J1040 Injection, methylprednisolone Methylprednisolone 80 inj acetate, 80 J1050 Injection, Medroxyprogesterone acetate medroxyprogesterone acetate, 1 J1051 Injection, Medroxyprogesterone inj medroxyprogesterone acetate, 50 J1055 Injection, Medrxyprogester acetate inj medroxyprogesterone acetate for contraceptive use, 150 J1056 Injection, medroxyprogesterone acetate / estradiol cypionate, 5 / 25 Ma/ec contraceptiveinjection

16 J1060 Injection, testosterone Testosterone cypionate 1 ml cypionate and estradiol cypionate, up to 1 ml J1070 Injection, testosterone Testosterone cypionat 100 cypionate, up to 100 J1071 Injection, testosterone Inj testosterone cypionate cypionate, 1 J1080 Injection, testosterone Testosterone cypionat 200 cypionate, 1 cc, 200 J1094 Injection, dexamethasone Inj dexamethasone acetate acetate, 1 J1100 Injection, dexamethasone Dexamethasone sodium phos sodium phosphate, 1 J1110 Injection, dihydroergotamine Inj dihydroergotamine mesylt mesylate, per 1 J1120 Injection, acetazolamide Acetazolamid sodium injectio sodium, up to 500 J1160 Injection, digoxin, up to 0.5 Digoxin injection J1162 Injection, digoxin immune fab Digoxin immune fab (ovine) (ovine), per vial J1165 Injection, phenytoin sodium, Phenytoin sodium injection per 50 J1170 Injection, hydromorphone, up Hydromorphone injection to 4 J1180 Injection, dyphylline, up to 500 Dyphylline injection J1190 Injection, dexrazoxane Dexrazoxane hcl injection hydrochloride, per 250 J1200 Injection, diphenhydramine Diphenhydramine hcl injectio hcl, up to 50 J1205 Injection, chlorothiazide Chlorothiazide sodium inj sodium, per 500 J1212 Injection, dmso, dimethyl Dimethyl sulfoxide 50% 50 ml sulfoxide, 50%, 50 ml J1230 Injection, methadone hcl, up Methadone injection to 10 J1240 Injection, dimenhydrinate, up Dimenhydrinate injection to 50 J1245 Injection, dipyridamole, per 10 Dipyridamole injection J1250 Injection, dobutamine Inj dobutamine hcl/250 hydrochloride, per 250 J1265 Injection, dopamine hcl, 40 Dopamine injection J1267 Injection, doripenem, 10 Doripenem injection J1270 Injection, doxercalciferol, 1 Injection, doxercalciferol mcg J1290 Injection, ecallantide, 1 Ecallantide injection J1300 Injection, eculizumab, 10 Eculizumab injection J1320 Injection, amitriptyline hcl, up to 20 Amitriptyline injection

17 J1322 Injection, elosulfase alfa, 1 Elosulfase alfa, injection J1324 Injection, enfuvirtide, 1 Enfuvirtide injection J1325 Injection, epoprostenol, 0.5 Epoprostenol injection J1327 Injection, eptifibatide, 5 Eptifibatide injection J1330 Injection, ergonovine maleate, Ergonovine maleate injection up to 0.2 J1335 Injection, ertapenem sodium, Ertapenem injection 500 J1364 Injection, erythromycin Erythro lactobionate /500 lactobionate, per 500 J1380 Injection, estradiol valerate, Estradiol valerate 10 inj up to 10 J1410 Injection, estrogen Inj estrogen conjugate 25 conjugated, per 25 J1430 Injection, ethanolamine Ethanolamine oleate 100 oleate, 100 J1435 Injection, estrone, per 1 Injection estrone per 1 J1436 Injection, etidronate disodium, Etidronate disodium inj per 300 J1438 administered under the direct Etanercept injection supervision of a physician, not for use when drug is self administered) J1439 Injection, ferric Inj ferric carboxymaltos 1 carboxymaltose, 1 J1440 Injection, filgrastim (g-csf), Filgrastim 300 mcg injection 300 mcg J1441 Injection, filgrastim (g-csf), Filgrastim 480 mcg injection 480 mcg J1442 Injection, filgrastim (g-csf), Inj filgrastim excl biosimil excludes biosimilars, 1 microgram J1443 Injection, ferric pyrophosphate Inj ferric pyrophosphate cit citrate solution, 0.1 of iron J1446 Injection, tbo-filgrastim, 5 Inj, tbo-filgrastim, 5 mcg micrograms J1447 Injection, tbo-filgrastim, 1 Inj tbo filgrastim 1 microg microgram J1450 Injection fluconazole, 200 Fluconazole J1451 Injection, fomepizole, 15 Fomepizole, 15 J1452 Injection, fomivirsen sodium, Intraocular fomivirsen na intraocular, 1.65 J1453 Injection, fosaprepitant, 1 Fosaprepitant injection J1455 Injection, foscarnet sodium, Foscarnet sodium injection per 1000 J1457 Injection, gallium nitrate, 1 Gallium nitrate injection J1458 Injection, galsulfase, 1 Galsulfase injection J1459 liquid), 500 Inj ivig privigen 500 J1460 Injection, gamma globulin, intramuscular, 1 cc Gamma globulin 1 cc inj

18 J1556 Injection, immune globulin Inj, imm glob bivigam, 500 (bivigam), 500 J1557 (e.g., liquid), 500 Gammaplex injection J1559 Injection, immune globulin Hizentra injection (hizentra), 100 J1560 Injection, gamma globulin, Gamma globulin > 10 cc inj intramuscular, over 10 cc J1561 liquid), 500 Gamunex-c/gammaked J1562 Injection, immune globulin Vivaglobin, inj (vivaglobin), 100 J1566 otherwise specified, 500 Immune globulin, powder J1568 liquid), 500 Octagam injection J1569 liquid), 500 Gammagard liquid injection J1570 Injection, ganciclovir sodium, Ganciclovir sodium injection 500 J1571 Injection, hepatitis b immune Hepagam b im injection globulin (hepagam b), intramuscular, 0.5 ml J1572 non-lyophilized (e.g., liquid), Flebogamma injection 500 J1573 Injection, hepatitis b immune Hepagam b intravenous, inj globulin (hepagam b), intravenous, 0.5 ml J1575 immuneglobulin Hyqvia 100 immuneglobulin J1580 Injection, garamycin, Garamycin gentamicin inj gentamicin, up to 80 J1590 Injection, gatifloxacin, 10 Gatifloxacin injection J1595 Injection, glatiramer acetate, Injection glatiramer acetate 20 J1599 otherwise specified, 500 Ivig non-lyophilized, nos J1600 Injection, gold sodium Gold sodium thiomaleate inj thiomalate, up to 50 J1602 Injection, golimumab, 1, Golimumab for iv use 1 for intravenous use J1610 Injection, glucagon Glucagon hydrochloride/1 hydrochloride, per 1 J1620 Injection, gonadorelin Gonadorelin hydroch/ 100 mcg hydrochloride, per 100 mcg J1626 Injection, granisetron Granisetron hcl injection hydrochloride, 100 mcg J1630 Injection, haloperidol, up to 5 Haloperidol injection J1631 Injection, haloperidol Haloperidol decanoate inj decanoate, per 50 J1640 Injection, hemin, 1 Hemin, 1 J1642 Injection, heparin sodium, Inj heparin sodium per 10 u (heparin lock flush), per 10 units J1644 Injection, heparin sodium, per Inj heparin sodium per 1000u 1000 units J1645 Injection, dalteparin sodium, per 2500 iu Dalteparin sodium

19 J1650 Injection, enoxaparin sodium, Inj enoxaparin sodium 10 J1652 Injection, fondaparinux Fondaparinux sodium sodium, 0.5 J1655 Injection, tinzaparin sodium, Tinzaparin sodium injection 1000 iu J1670 Injection, tetanus immune Tetanus immune globulin inj globulin, human, up to 250 units J1675 Injection, histrelin acetate, 10 Histrelin acetate micrograms J1680 Injection, human fibrinogen Human fibrinogen conc inj concentrate, 100 J1700 Injection, hydrocortisone Hydrocortisone acetate inj acetate, up to 25 J1710 Injection, hydrocortisone Hydrocortisone sodium ph inj sodium phosphate, up to 50 J1720 Injection, hydrocortisone Hydrocortisone sodium succ i sodium succinate, up to 100 J1725 Injection, Hydroxyprogesterone caproate hydroxyprogesterone caproate, 1 J1730 Injection, diazoxide, up to 300 Diazoxide injection J1740 Injection, ibandronate sodium, Ibandronate sodium injection 1 J1741 Injection, ibuprofen, 100 Ibuprofen injection J1742 Injection, ibutilide fumarate, 1 Ibutilide fumarate injection J1743 Injection, idursulfase, 1 Idursulfase injection J1744 Injection, icatibant, 1 Icatibant injection J1745 Injection infliximab, 10 Infliximab injection J1750 Injection, iron dextran, 50 Inj iron dextran J1756 Injection, iron sucrose, 1 Iron sucrose injection J1786 Injection, imiglucerase, 10 Imuglucerase injection units J1790 Injection, droperidol, up to 5 Droperidol injection J1800 Injection, propranolol hcl, up Propranolol injection to 1 J1810 Injection, droperidol and Droperidol/fentanyl inj fentanyl citrate, up to 2 ml ampule J1815 Injection, insulin, per 5 units Insulin injection J1826 Injection, interferon beta-1a, Interferon beta-1a inj 30 mcg J1830 when drug administered under the direct supervision of a physician, not for use when drug is self administered) Interferon beta-1b /.25

20 J1833 Injection, isavuconazonium, 1 Injection, isavuconazonium J1835 Injection, itraconazole, 50 Itraconazole injection J1840 Injection, kanamycin sulfate, Kanamycin sulfate 500 inj up to 500 J1850 Injection, kanamycin sulfate, Kanamycin sulfate 75 inj up to 75 J1885 Injection, ketorolac Ketorolac tromethamine inj tromethamine, per 15 J1890 Injection, cephalothin sodium, Cephalothin sodium injection up to 1 gram J1930 Injection, lanreotide, 1 Lanreotide injection J1931 Injection, laronidase, 0.1 Laronidase injection J1940 Injection, furosemide, up to 20 Furosemide injection J1945 Injection, lepirudin, 50 Lepirudin J1950 Injection, leuprolide acetate Leuprolide acetate /3.75 (for depot suspension), per 3.75 J1953 Injection, levetiracetam, 10 Levetiracetam injection J1955 Injection, levocarnitine, per 1 Inj levocarnitine per 1 gm gm J1956 Injection, levofloxacin, 250 Levofloxacin injection J1960 Injection, levorphanol tartrate, Levorphanol tartrate inj up to 2 J1980 Injection, hyoscyamine Hyoscyamine sulfate inj sulfate, up to 0.25 J1990 Injection, chlordiazepoxide Chlordiazepoxide injection hcl, up to 100 J2001 Injection, lidocaine hcl for Lidocaine injection intravenous infusion, 10 J2010 Injection, lincomycin hcl, up to Lincomycin injection 300 J2020 Injection, linezolid, 200 Linezolid injection J2060 Injection, lorazepam, 2 Lorazepam injection J2150 Injection, mannitol, 25% in 50 Mannitol injection ml J2170 Injection, mecasermin, 1 Mecasermin injection J2175 Injection, meperidine Meperidine hydrochl /100 hydrochloride, per 100 J2180 Injection, meperidine and Meperidine/promethazine inj promethazine hcl, up to 50 J2185 Injection, meropenem, 100 Meropenem J2210 Injection, methylergonovine Methylergonovin maleate inj maleate, up to 0.2 J2212 Injection, methylnaltrexone, Methylnaltrexone injection 0.1 J2248 Injection, micafungin sodium, Micafungin sodium injection 1 J2250 Injection, midazolam Inj midazolam hydrochloride

21 hydrochloride, per 1 J2260 Injection, milrinone lactate, 5 Inj milrinone lactate / 5 J2265 Injection, minocycline Minocycline hydrochloride hydrochloride, 1 J2270 Injection, morphine sulfate, up Morphine sulfate injection to 10 J2271 Injection, morphine sulfate, Morphine so4 injection J2274 use, 10 In morphine preservativ free J2275 Injection, morphine sulfate Morphine sulfate injection (preservative-free sterile solution), per 10 J2278 Injection, ziconotide, 1 Ziconotide injection microgram J2280 Injection, moxifloxacin, 100 Inj, moxifloxacin 100 J2300 Injection, nalbuphine Inj nalbuphine hydrochloride hydrochloride, per 10 J2310 Injection, naloxone Inj naloxone hydrochloride hydrochloride, per 1 J2315 Injection, naltrexone, depot Naltrexone, depot form form, 1 J2320 Injection, nandrolone Nandrolone decanoate 50 decanoate, up to 50 J2323 Injection, natalizumab, 1 Natalizumab injection J2325 Injection, nesiritide, 0.1 Nesiritide injection J2353 Injection, octreotide, depot Octreotide injection, depot form for intramuscular injection, 1 J2354 injection, 25 mcg Octreotide inj, non-depot J2355 Injection, oprelvekin, 5 Oprelvekin injection J2357 Injection, omalizumab, 5 Omalizumab injection J2358 Injection, olanzapine, longacting, Olanzapine long-acting inj 1 J2360 Injection, orphenadrine citrate, Orphenadrine injection up to 60 J2370 Injection, phenylephrine hcl, Phenylephrine hcl injection up to 1 ml J2400 Injection, chloroprocaine Chloroprocaine hcl injection hydrochloride, per 30 ml J2405 Injection, ondansetron Ondansetron hcl injection hydrochloride, per 1 J2407 Injection, oritavancin, 10 Injection, oritavancin J2410 Injection, oxymorphone hcl, Oxymorphone hcl injection up to 1 J2425 Injection, palifermin, 50 Palifermin injection micrograms J2426 Injection, paliperidone Paliperidone palmitate inj palmitate extended release, 1 J2430 Injection, pamidronate Pamidronate disodium /30

22 disodium, per 30 J2440 Injection, papaverine hcl, up Papaverin hcl injection to 60 J2460 Injection, oxytetracycline hcl, Oxytetracycline injection up to 50 J2469 Injection, palonosetron hcl, 25 Palonosetron hcl mcg J2501 Injection, paricalcitol, 1 mcg Paricalcitol J2502 Injection, pasireotide long Inj, pasireotide long acting acting, 1 J2503 Injection, pegaptanib sodium, Pegaptanib sodium injection 0.3 J2504 Injection, pegademase Pegademase bovine, 25 iu bovine, 25 iu J2505 Injection, pegfilgrastim, 6 Injection, pegfilgrastim 6 J2507 Injection, pegloticase, 1 Pegloticase injection J2510 Injection, penicillin g procaine, Penicillin g procaine inj aqueous, up to 600,000 units J2513 Injection, pentastarch, 10% Pentastarch 10% solution solution, 100 ml J2515 Injection, pentobarbital Pentobarbital sodium inj sodium, per 50 J2540 Injection, penicillin g Penicillin g potassium inj potassium, up to 600,000 units J2543 (1.125 grams) Piperacillin/tazobactam J2547 Injection, peramivir, 1 Injection, peramivir J2550 Injection, promethazine hcl, Promethazine hcl injection up to 50 J2560 Injection, phenobarbital Phenobarbital sodium inj sodium, up to 120 J2562 Injection, plerixafor, 1 Plerixafor injection J2590 Injection, oxytocin, up to 10 Oxytocin injection units J2597 Injection, desmopressin Inj desmopressin acetate acetate, per 1 mcg J2650 Injection, prednisolone Prednisolone acetate inj acetate, up to 1 ml J2670 Injection, tolazoline hcl, up to Totazoline hcl injection 25 J2675 Injection, progesterone, per Inj progesterone per J2680 Injection, fluphenazine Fluphenazine decanoate 25 decanoate, up to 25 J2690 Injection, procainamide hcl, up Procainamide hcl injection to 1 gm J2700 Injection, oxacillin sodium, up Oxacillin sodium injeciton to 250 J2704 Injection, propofol, 10 Inj, propofol, 10 J2710 Injection, neostigmine methylsulfate, up to 0.5 Neostigmine methylslfte inj

23 J2720 Injection, protamine sulfate, Inj protamine sulfate/10 per 10 J2724 Injection, protein c Protein c concentrate concentrate, intravenous, human, 10 iu J2725 Injection, protirelin, per 250 Inj protirelin per 250 mcg mcg J2730 Injection, pralidoxime chloride, Pralidoxime chloride inj up to 1 gm J2760 Injection, phentolamine Phentolaine mesylate inj mesylate, up to 5 J2765 Injection, metoclopramide hcl, Metoclopramide hcl injection up to 10 J2770 Injection, Quinupristin/dalfopristin quinupristin/dalfopristin, 500 (150/350) J2778 Injection, ranibizumab, 0.1 Ranibizumab injection J2780 Injection, ranitidine Ranitidine hydrochloride inj hydrochloride, 25 J2783 Injection, rasburicase, 0.5 Rasburicase J2785 Injection, regadenoson, 0.1 Regadenoson injection J2788 i.u.) Rho d immune globulin 50 mcg J2790 i.u.) Rho d immune globulin inj J2791 intravenous, 100 iu Rhophylac injection J iu Rho(d) immune globulin h, sd J2793 Injection, rilonacept, 1 Rilonacept injection J2794 Injection, risperidone, long Risperidone, long acting acting, 0.5 J2795 Injection, ropivacaine Ropivacaine hcl injection hydrochloride, 1 J2796 Injection, romiplostim, 10 Romiplostim injection micrograms J2800 Injection, methocarbamol, up Methocarbamol injection to 10 ml J2805 Injection, sincalide, 5 Sincalide injection micrograms J2810 Injection, theophylline, per 40 Inj theophylline per 40 J2820 Injection, sargramostim (gmcsf), Sargramostim injection 50 mcg J2850 Injection, secretin, synthetic, Inj secretin synthetic human human, 1 microgram J2860 Injection, siltuximab, 10 Injection, siltuximab J2910 Injection, aurothioglucose, up Aurothioglucose injeciton to 50 J2916 Injection, sodium ferric Na ferric gluconate complex gluconate complex in sucrose injection, 12.5 J2920 Injection, methylprednisolone sodium succinate, up to 40 Methylprednisolone injection

24 J2930 Injection, methylprednisolone Methylprednisolone injection sodium succinate, up to 125 J2940 Injection, somatrem, 1 Somatrem injection J2941 Injection, somatropin, 1 Somatropin injection J2950 Injection, promazine hcl, up to Promazine hcl injection 25 J2993 Injection, reteplase, 18.1 Reteplase injection J2995 Injection, streptokinase, per Inj streptokinase / iu 250,000 iu J2997 Injection, alteplase Alteplase recombinant recombinant, 1 J3000 Injection, streptomycin, up to Streptomycin injection 1 gm J3010 Injection, fentanyl citrate, 0.1 Fentanyl citrate injeciton J3030 when drug administered under Sumatriptan succinate / 6 the direct supervision of a physician, not for use when drug is self administered) J3060 Injection, taliglucerace alfa, 10 Inj, taliglucerace alfa 10 u units J3070 Injection, pentazocine, 30 Pentazocine injection J3090 Injection, tedizolid phosphate, Inj tedizolid phosphate 1 J3095 Injection, telavancin, 10 Telavancin injection J3101 Injection, tenecteplase, 1 Tenecteplase injection J3105 Injection, terbutaline sulfate, Terbutaline sulfate inj up to 1 J3110 Injection, teriparatide, 10 mcg Teriparatide injection J3120 Injection, testosterone Testosterone enanthate inj enanthate, up to 100 J3121 Injection, testosterone Inj testostero enanthate 1 enanthate, 1 J3130 Injection, testosterone Testosterone enanthate inj enanthate, up to 200 J3140 Injection, testosterone Testosterone suspension inj suspension, up to 50 J3145 Injection, testosterone Testosterone undecanoate 1 undecanoate, 1 J3150 Injection, testosterone Testosteron propionate inj propionate, up to 100 J3230 Injection, chlorpromazine hcl, Chlorpromazine hcl injection up to 50 J3240 Injection, thyrotropin alpha, Thyrotropin injection 0.9, provided in 1.1 vial J3243 Injection, tigecycline, 1 Tigecycline injection J3246 Injection, tirofiban hcl, 0.25 Tirofiban hcl J3250 Injection, trimethobenzamide hcl, up to 200 Trimethobenzamide hcl inj

25 J3260 Injection, tobramycin sulfate, Tobramycin sulfate injection up to 80 J3262 Injection, tocilizumab, 1 Tocilizumab injection J3265 Injection, torsemide, 10 /ml Injection torsemide 10 /ml J3280 Injection, thiethylperazine Thiethylperazine maleate inj maleate, up to 10 J3285 Injection, treprostinil, 1 Treprostinil injection J3300 Injection, triamcinolone Triamcinolone a inj prs-free acetonide, preservative free, 1 J3301 Injection, triamcinolone Triamcinolone acet inj nos acetonide, not otherwise specified, 10 J3302 Injection, triamcinolone Triamcinolone diacetate inj diacetate, per 5 J3303 Injection, triamcinolone Triamcinolone hexacetonl inj hexacetonide, per 5 J3305 Injection, trimetrexate Inj trimetrexate glucoronate glucuronate, per 25 J3310 Injection, perphenazine, up to Perphenazine injeciton 5 J3315 Injection, triptorelin pamoate, Triptorelin pamoate 3.75 J3320 Injection, spectinomycin Spectinomycn di-hcl inj dihydrochloride, up to 2 gm J3350 Injection, urea, up to 40 gm Urea injection J3355 Injection, urofollitropin, 75 iu Urofollitropin, 75 iu J3357 Injection, ustekinumab, 1 Ustekinumab injection J3360 Injection, diazepam, up to 5 Diazepam injection J3364 Injection, urokinase, 5000 iu Urokinase 5000 iu injection vial J3365 Injection, iv, urokinase, Urokinase 250,000 iu inj 250,000 i.u. vial J3370 Injection, vancomycin hcl, 500 Vancomycin hcl injection J3380 Injection, vedolizumab, 1 Injection, vedolizumab J3385 Injection, velaglucerase alfa, Velaglucerase alfa 100 units J3396 Injection, verteporfin, 0.1 Verteporfin injection J3400 Injection, triflupromazine hcl, Triflupromazine hcl inj up to 20 J3410 Injection, hydroxyzine hcl, up Hydroxyzine hcl injection to 25 J3411 Injection, thiamine hcl, 100 Thiamine hcl 100 J3415 Injection, pyridoxine hcl, 100 Pyridoxine hcl 100 J3420 Injection, vitamin b-12 Vitamin b12 injection cyanocobalamin, up to 1000 mcg J3430 Injection, phytonadione (vitamin k), per 1 Vitamin k phytonadione inj

26 J3465 Injection, voriconazole, 10 Injection, voriconazole J3470 Injection, hyaluronidase, up to Hyaluronidase injection 150 units J3471 usp units) Ovine, up to 999 usp units J3472 Injection, hyaluronidase, Ovine, 1000 usp units ovine, preservative free, per 1000 usp units J3473 Injection, hyaluronidase, Hyaluronidase recombinant recombinant, 1 usp unit J3475 Injection, magnesium sulfate, Inj magnesium sulfate per 500 J3480 Injection, potassium chloride, Inj potassium chloride per 2 meq J3485 Injection, zidovudine, 10 Zidovudine J3486 Injection, ziprasidone Ziprasidone mesylate mesylate, 10 J3487 Injection, zoledronic acid Zoledronic acid (zometa), 1 J3488 Injection, zoledronic acid Reclast injection (reclast), 1 J3489 Injection, zoledronic acid, 1 Zoledronic acid 1 J3490 Unclassified drugs Drugs unclassified injection J3520 Edetate disodium, per 150 Edetate disodium per 150 J3530 Nasal vaccine inhalation Nasal vaccine inhalation J3535 Drug administered through a Metered dose inhaler drug metered dose inhaler J3570 Laetrile, amygdalin, vitamin Laetrile amygdalin vit b17 b17 J3590 Unclassified biologics Unclassified biologics J7030 Infusion, normal saline Normal saline solution infus solution, 1000 cc J7040 Infusion, normal saline Normal saline solution infus solution, sterile (500 ml=1 unit) J7042 5% dextrose/normal saline 5% dextrose/normal saline (500 ml = 1 unit) J7050 Infusion, normal saline Normal saline solution infus solution, 250 cc J7060 5% dextrose/water (500 ml = 5% dextrose/water 1 unit) J7070 Infusion, d5w, 1000 cc D5w infusion J7100 Infusion, dextran 40, 500 ml Dextran 40 infusion J7110 Infusion, dextran 75, 500 ml Dextran 75 infusion J7120 Ringers lactate infusion, up to Ringers lactate infusion 1000 cc J7121 5% dextrose in lactated 5% dextrose in lac ringers ringers infusion, up to 1000 cc J7131 Hypertonic saline solution, 1 Hypertonic saline sol ml J7178 Injection, human fibrinogen Human fibrinogen conc inj

27 concentrate, 1 J7180 Injection, factor xiii Factor xiii anti-hem factor (antihemophilic factor, human), 1 i.u. J7181 Injection, factor xiii a-subunit, Factor xiii recomb a-subunit (recombinant), per iu J7182 iu Factor viii recomb novoeight J7183 Injection, von willebrand factor Wilate injection complex (human), wilate, 1 i.u. vwf:rco J7185 Injection, factor viii Xyntha inj (antihemophilic factor, recombinant) (xyntha), per i.u. J7186 per factor viii i.u. Antihemophilic viii/vwf comp J7187 Injection, von willebrand factor Humate-p, inj complex (humate-p), per iu vwf:rco J7188 Injection, factor viii Factor viii recomb obizur (antihemophilic factor, recombinant), (obizur), per i.u. J7189 Factor viia (antihemophilic Factor viia factor, recombinant), per 1 microgram J7190 Factor viii (antihemophilic Factor viii factor, human) per i.u. J7191 Factor viii (antihemophilic Factor viii (porcine) factor (porcine)), per i.u. J7192 specified Factor viii recombinant nos J7193 Factor ix (antihemophilic Factor ix non-recombinant factor, purified, nonrecombinant) per i.u. J7194 Factor ix, complex, per i.u. Factor ix complex J7195 otherwise specified Factor ix recombinant nos J7196 Injection, antithrombin Antithrombin recombinant recombinant, 50 i.u. J7197 Antithrombin iii (human), per Antithrombin iii injection i.u. J7198 Anti-inhibitor, per i.u. Anti-inhibitor J7199 Hemophilia clotting factor, not Hemophilia clot factor noc otherwise classified J7200 Injection, factor ix, Factor ix recombinan rixubis (antihemophilic factor, recombinant), rixubis, per iu J7201 Injection, factor ix, fc fusion Factor ix fc fusion recomb protein (recombinant), per iu J7205 Injection, factor viii fc fusion Factor viii fc fusion recomb (recombinant), per iu J7308 form (354 ) Aminolevulinic acid hcl top J7309 Methyl aminolevulinate (mal) Methyl aminolevulinate, top for topical administration, 16.8%, 1 gram J7310 Ganciclovir, 4.5, long- Ganciclovir long act implant