Outpatient Drugs Payment Policy

Transcription

1 Policy Outpatient Drugs Payment Policy Fallon Community Health Plan (FCHP) reimburses contracted providers for the provision of covered FDA-approved non-self administered drugs when given in an outpatient setting. This policy also applies to drugs administered by a provider via an implantable drug delivery system and to brachytherapy sources. FCHP anticipates that providers will administer drugs to members in such a way that they can use drugs most efficiently, in a clinically appropriate manner. FCHP does not reimburse for that portion of a multi-use vial of medication that is not administered to FCHP members including, but not limited to, those that are determined to be contaminated, wasted or unused. When drugs are eligible for separate reimbursement, FCHP s reimbursement is for pharmaceuticals which are administered to a FCHP member, only up to the next incremental Level II HCPCS code unit. Benefits application FCHP Direct Care/FCHP Select Care Commonwealth Care Companion Care FCHP MassHealth Fallon Preferred Care PPO Fallon Senior Plan HMO Fallon Senior Plan PPO Summit ElderCare NaviCare Reimbursement FCHP anticipates that providers will administer drugs to members in such a way that they can use drugs most efficiently, in a clinically appropriate manner. FCHP reimburses the provision of covered FDA-approved non-self administered drugs when given in an outpatient setting. FCHP s reimbursement is for pharmaceuticals which are administered to a FCHP member, only up to the next incremental Level II HCPCS code unit. FCHP does not reimburse for that portion of a multi-use vial of medication that is not administered to FCHP members including, but not limited to, those that are determined to be contaminated, wasted or unused, FCHP does not reimburse for that portion of a single-use vial of medication that is not administered to a FCHP member including, but not limited to, those that are determined to be contaminated, wasted or unused, unless documentation within the patient s medical record file indicates the date, time, and name of clinical staff who wasted the portion of medication within a single-use vial. FCHP anticipates that the provider will utilize the most appropriate sized single-use vial or combination of single-use vials to deliver the ordered dose of medication and minimize waste. Outpatient Drugs Payment Policy Page 1 of 13 effective 07/01/2014

2 Reimbursement will be made in accordance with contracted rates. Referral/notification/prior authorization requirements The facility or ordering physician is required to obtain prior authorization for: drugs on the list of formulary medications that require prior authorization. This list can be found in the Provider Pharmacy section of the FCHP Web site and drugs with HCPCS codes found on the List of Procedures Requiring Prior Authorization located in the Managing Patient Care section of the Provider Manual under PCP Referral and Plan Prior Authorization Process. Pharmacy Prior Authorization Forms must be completed and faxed to For urgent situations, please call and select option 5. Billing/coding guidelines Bill pharmaceuticals with both the NDC number and the appropriate Level II HCPCS codes; bill with a count when indicated. As of February 1, 2013, MassHealth requires NDC information on all Single-Source Drugs as defined by CMS, with the exceptions listed below: 1. Inpatient Claims 2. Outpatient claims that are part of a bundled rate or global fee 3. Claims purchased under the 340B drug discount program/claims from providers listed on the Office of Pharmacy Affairs website as participating in Medicaid. 4. Radiopharmaceuticals** 5. Contrast media 6. Vaccines 7. Devices **CMS plans to issue new guidance to require NDC information for radiopharmaceuticals. With the exception of the scenarios listed above, claims for services for FCHP members enrolled through MassHealth that are submitted without NDC information will be denied. In order to be paid, a claim adjustment request with the NDC information will need to be submitted to FCHP. MassHealth will supply a list of HCPCS that require NDC codes to FCHP. This list is exhibit A of this policy. This list will be updated quarterly beginning in the second quarter of calendar year Pharmaceutical Waste For multi-use vials, bill only for the portion of the medication administered to the member; wasted pharmaceutical will not be reimbursed. FCHP does not require but will accept modifier JW drug amount discarded/not administered to any patient to identify drugs where the dosage contained in the single-use vial is greater than ordered and/or administered. FCHP anticipates that providers will administer drugs to members in such a way that they can use drugs most efficiently, in a clinically appropriate manner. FCHP also anticipates that the provider will utilize the most appropriate sized single-use vial or combination of single-use vials to deliver the ordered dose of medication and minimize waste. FCHP s reimbursement is for pharmaceuticals which are administered to a FCHP member, only up to the next incremental Level II HCPCS code unit. Wasted pharmaceutical from a single-use vial will be reimbursed when the wasted medication is documented as such within the patient s medical record. Such documentation should include the date, time and name of the clinical staff wasting the pharmaceutical, as well as the amount of wasted medication. Documentation of waste must be retained within the patient s medical record and/or made available to FHCP audit representatives upon request. Outpatient Drugs Payment Policy Page 2 of 13

3 Claims submitted with Revenue Code 0636 must include the HCPCS code. FCHP reserves the right to audit to verify payment accuracy. Neither FCHP nor FCHP members can be held financially responsible for any denied payments for pharmaceuticals that were not administered. Electronic claim submitters Submit both the HCPCS J code and NDC number in the HIPAA-compliant format. Paper claim submitters CMS-1500 form Bill both the HCPCS J code and NDC number in field 24D; place the NDC number under the Level II HCPCS code; bill units in field 24G. UB-04 form Bill the Level II HCPCS code in field locator 44; the NDC number in field locator 43; service units in field locator 46. Place of service This policy applies to services rendered in the outpatient setting. Policy history Origination date: 11/1/09 Previous revision date(s): 07/01/2010 updated language in the Policy, Reimbursement and Billing/coding guidelines sections to indicate policy and process regarding pharmaceutical waste. 01/01/ Updated billing/coding guidelines to add discussion about revenue code /01/ Removed requirement for itemized invoice with revenue code /1/2012 Removed requirement to submit modifier JW - drug amount discarded and that the amount discarded from single-use vial drugs will not be reimbursed. 02/01/2013 Updated NDC billing requirements for members enrolled through MassHealth. 09/01/ Updated discussion of drug waste and reimbursement for multi vs. single use vials. Connection date & details: May 2014 Clarified discussion about drug waste. This payment policy has been developed to provide information regarding general billing, coding and documentation guidelines for FCHP. Even though this payment policy may indicate that a particular service or supply is considered covered, specific provider contract terms and/or member individual benefit plans may apply and this policy is not a guarantee of payment. FCHP reserves the right to apply this payment policy to all FCHP companies and subsidiaries. FCHP routinely verifies that charges billed are in accordance with the guidelines stated in this payment policy and are appropriately documented in the medical records. Payments are subject to postpayment audits and retraction of overpayments. Outpatient Drugs Payment Policy Page 3 of 13

4 Exhibit A HCPCS that require NDC codes for MassHealth MassHealth requires NDC information on all Single-Source Drugs as defined by CMS, with some exceptions. MassHealth will supply a list of HCPCS that require NDC codes to FCHP. This list is exhibit A of this policy. This list will be updated quarterly beginning in the second quarter of calendar year Claims for services for FCHP members enrolled through MassHealth with the following HCPCS codes that are submitted without NDC information will be denied. In order to be paid, a claim adjustment request with the NDC information will need to be submitted to FCHP. HCPCS SHORT DESCRIPTOR DRUG NAME HCPCS DOSAGE J0129 Abatacept injection Abatacept 10 MG J0130 Abciximab injection Reopro 10 MG J0135 Adalimumab injection Humira 20 MG J0152 Adenosine injection Adenoscan 30 MG J0180 Agalsidase beta injection Fabrazyme 1 MG J0207 Amifostine Ethyol 500 MG J0215 Alefacept Amevive 0.5 MG J0220 Alglucosidase alfa injection Myozyme 10 MG J0221 Lumizyme injection Lumizyme 10 MG J0256 Alpha 1 proteinase inhibitor Aralast NP 10 MG J0256 Alpha 1 proteinase inhibitor Zemaira 10 MG J0257 Glassia injection GLASSIA 10 MG J0287 Amphotericin b lipid complex Abelcet 10 MG J0288 Ampho b cholesteryl sulfate Amphotec 10 MG J0289 Amphotericin b liposome inj Ambisome 10 MG J0348 Anidulafungin injection ERAXIS 1 MG J0400 Aripiprazole injection Aripiprazole IM inj 0.25 MG J0470 Dimecaprol injection Bal In Oil 100 MG J0480 Basiliximab Simulect 20 MG J0490 Belimumab injection BENLYSTA 10 MG J0515 Inj benztropine mesylate Cogentin 1 MG J0558 PenG benzathine/procaine inj Bicillin CR Pediatric 100,000 UNITS J0558 PenG benzathine/procaine inj BICILLIN C-R 100,000 UNITS J0583 Bivalirudin Angiomax 1 MG J0585 Injection,onabotulinumtoxinA Botox Cosmetic 1 UNIT J0585 Injection,onabotulinumtoxinA Botox 1 UNIT J0586 AbobotulinumtoxinA Dysport 5 Unit J0587 Inj, rimabotulinumtoxinb Myobloc 100 UNITS J0588 Incobotulinumtoxin A XEOMIN 1 UNIT J0594 Busulfan injection BUSULFAN 1 MG Outpatient Drugs Payment Policy Page 4 of 13

5 J0597 C-1 esterase, berinert BERINERT 10 UNITS J0598 C-1 esterase, cinryze Cinryze 10 UNITS J0630 Calcitonin salmon injection Miacalcin 400 UNITS J0637 Caspofungin acetate Cancidas 5 MG J0638 Canakinumab injection ILARIS 1 MG J0641 Levoleucovorin injection Levoleucovorin Calcium 0.5 MG J0697 Sterile cefuroxime injection Zinacef In D5W 750 MG J0697 Sterile cefuroxime injection Zinacef In Sterile Water 750 MG J0698 Cefotaxime sodium injection Claforan In D5W 1 GM J0698 Cefotaxime sodium injection Claforan 1 GM J0712 Ceftaroline fosamil inj Teflaro 10 MG J0713 Inj ceftazidime per 500 mg Fortaz In D5W 500 MG J0718 Certolizumab pegol inj CIMZIA 1 MG J0740 Cidofovir injection Vistide 375 MG J0743 Cilastatin sodium injection Primaxin Iv 250 MG J0744 Ciprofloxacin iv CIPROFLOXACIN 200 MG J0775 Collagenase, clost hist inj XIAFLEX (collagenase clostridium histolyticum) 0.01 MG J0850 Cytomegalovirus imm IV /vial CYTOGAM PER VIAL J0878 Daptomycin injection Cubicin 1 MG J0881 Darbepoetin alfa, non-esrd Aranesp 1 MCG J0882 Darbepoetin alfa, esrd use Aranesp 1 MCG J0885 Epoetin alfa, non-esrd Epogen 1000 UNITS J0885 Epoetin alfa, non-esrd Procrit 1000 UNITS J0886 Epoetin alfa 1000 units ESRD Epogen 1000 UNITS J0886 Epoetin alfa 1000 units ESRD Procrit 1000 UNITS J0894 Decitabine injection decitabine 1 MG J0897 Denosumab injection Prolia 1 MG J0897 Denosumab injection XGEVA 1 MG J1051 Medroxyprogesterone inj Depo-Provera 50 MG J1170 Hydromorphone injection Hydromorphone Hcl 4 MG J1205 Chlorothiazide sodium inj Diuril Iv 500 MG J1230 Methadone injection Methadone Hcl 10 MG J1260 Dolasetron mesylate Anzemet 10 MG J1267 Doripenem injection DORIBAX 10 MG J1270 Injection, doxercalciferol Hectorol 1 MCG J1290 Ecallantide injection KALBITOR 1 MG J1300 Eculizumab injection Soliris 10 MG J1325 Epoprostenol injection Epoprostenol 0.5 MG J1327 Eptifibatide injection Integrilin 5 MG J1335 Ertapenem injection Invanz 500 MG Outpatient Drugs Payment Policy Page 5 of 13

6 J1410 Inj estrogen conjugate 25 MG Premarin 25 MG J1438 Etanercept injection Enbrel (Etanercept) 25 MG J1438 Etanercept injection Enbrel 25 MG J1440 Filgrastim 300 mcg injection Neupogen 300 MCG J1441 Filgrastim 480 mcg injection Neupogen 480 MCG J1451 Fomepizole, 15 mg Antizol 15 MG EMEND FOR INJECTION J1453 Fosaprepitant injection 150MG 1 MG J1453 Fosaprepitant injection EMEND FOR INJECTION 1 MG J1459 Inj IVIG privigen 500 mg Privigen 500 MG J1557 Gammaplex injection GAMMAPLEX 500 MG J1559 Hizentra injection Hizentra 100 MG J1561 Gamunex, Gamunex-C, Gammaked Gamunex 500 MG J1561 Gamunex, Gamunex-C, Gammaked Gamunex-C 500 MG J1566 Immune globulin, powder Gammagard S/D 500 MG J1566 Immune globulin, powder Carimune Nf 500 MG J1568 Octagam injection Octagam 5%, 5 g in 100 ml 500 MG J1568 Octagam injection Octagam 5%, 25 g in 500 ml 500 MG J1568 Octagam injection Octagam 5%, 2.5 g in 50 ml 500 MG J1568 Octagam injection Octagam 5%, 1 g in 20 ml 500 MG J1568 Octagam injection Octagam 500 MG J1569 Gammagard liquid injection GAMMAGARD LIQUID 500 MG J1571 Hepagam b im injection CBI HepaGam B 1 ml 0.5 ML J1571 Hepagam b im injection CBI HepaGam B 5 ml 0.5 ML J1571 Hepagam b im injection Nova HepaGam B 1 ml 0.5 ML J1571 Hepagam b im injection Nova HepaGam B 5 ml 0.5 ML J1572 Flebogamma injection Flebogamma DIF 500 MG J1572 Flebogamma injection FLEBOGAMMA 10% DIF 500 MG J1573 Hepagam b intravenous, inj Nova HepaGam B 1 ml 0.5 ML J1573 Hepagam b intravenous, inj Nova HepaGam B 5 ml 0.5 ML J1573 Hepagam b intravenous, inj CBI HepaGam B 1 ml 0.5 ML J1573 Hepagam b intravenous, inj CBI HepaGam B 5 ml 0.5 ML GLUCAGON J1610 Glucagon hydrochloride/1 MG HYDROCHLORIDE 1 MG J1610 Glucagon hydrochloride/1 MG Glucagon Emergency 1 MG J1640 Hemin, 1 mg Panhematin 1 MG J1645 Dalteparin sodium Fragmin 2500 IU J1650 Inj enoxaparin sodium Lovenox 10 MG J1670 Tetanus immune globulin inj HYPERTET S/D 250 UNITS J1740 Ibandronate sodium injection BONIVA 1 MG J1740 Ibandronate sodium injection Ibandronate sodium 1 MG Outpatient Drugs Payment Policy Page 6 of 13

7 J1743 Idursulfase injection Idursulfase 1 MG J1745 Infliximab injection Remicade 10 MG J1750 Inj iron dextran Dexferrum 50 MG J1756 Iron sucrose injection Venofer 1 MG J1786 Imuglucerase injection Cerezyme 10 UNITS J1815 Insulin injection Humalog 5 UNITS J1815 Insulin injection Humalog Pen 5 UNITS J1815 Insulin injection Humulin 70/30 5 UNITS J1815 Insulin injection Humulin 70/30 Pen 5 UNITS J1815 Insulin injection HUMULIN N 5 UNITS J1815 Insulin injection Humulin N Pen 5 UNITS J1815 Insulin injection Humulin R 5 UNITS J1815 Insulin injection Novolog Mix 70/30 Flexpen 5 UNITS J1815 Insulin injection Novolin N 5 UNITS J1815 Insulin injection Novolog Penfill 5 UNITS J1815 Insulin injection Novolin R 5 UNITS J1815 Insulin injection Novolog 5 UNITS J1815 Insulin injection Novolog Flexpen 5 UNITS J1815 Insulin injection Novolog Mix 70/30 5 UNITS J1815 Insulin injection Humalog Mix 75/25 5 UNITS J1815 Insulin injection Novolin 70/30 5 UNITS J1817 Insulin for insulin pump use Novolog Penfill 50 UNITS J1817 Insulin for insulin pump use Novolog Mix 70/30 Flexpen 50 UNITS J1817 Insulin for insulin pump use Novolog Mix 70/30 50 UNITS J1817 Insulin for insulin pump use Novolog Flexpen 50 UNITS J1817 Insulin for insulin pump use Novolog 50 UNITS J1817 Insulin for insulin pump use Novolin R 50 UNITS J1817 Insulin for insulin pump use Novolin N 50 UNITS J1817 Insulin for insulin pump use Novolin 70/30 50 UNITS J1817 Insulin for insulin pump use Humulin R 50 UNITS J1817 Insulin for insulin pump use Humulin N Pen 50 UNITS J1817 Insulin for insulin pump use Humulin N 50 UNITS J1817 Insulin for insulin pump use Humulin 70/30 Pen 50 UNITS J1817 Insulin for insulin pump use Humalog Mix 75/25 50 UNITS J1817 Insulin for insulin pump use Humalog Pen 50 UNITS J1817 Insulin for insulin pump use HUMULIN 70/30 50 UNITS J1817 Insulin for insulin pump use Humalog 50 UNITS J1930 Lanreotide injection SOMATULINE DEPOT 1 MG J1931 Laronidase injection Aldurazyme 0.1 MG J1945 Lepirudin Refludan 50 MG J1950 Leuprolide acetate /3.75 MG LUPRON DEPOT 3.75MG 3.75 MG Outpatient Drugs Payment Policy Page 7 of 13

8 J1950 J1950 Leuprolide acetate /3.75 MG Leuprolide acetate /3.75 MG LUPRON DEPOT 3-MONTH, 11.25MG LUPRON DEPOT-PED 3- MONTH, 30 MG 3.75 MG 3.75 MG J1950 Leuprolide acetate /3.75 MG Lupron Depot-Ped 11.25mg 3.75 MG J1950 Leuprolide acetate /3.75 MG LUPRON DEPOT-PED 3- MONTH, 11.25MG 3.75 MG J1953 Levetiracetam injection Levetiracetam (Keppra) 10 MG J1953 Levetiracetam injection Levetiracetam 10 MG J2020 Linezolid injection Zyvox 200 MG J2248 Micafungin sodium injection Micafungin sodium (Mycamine) 1 MG J2278 Ziconotide injection Prialt 1 MCG J2280 Inj, moxifloxacin 100 mg Avelox 100 MG J2315 Naltrexone, depot form Vivitrol 1 MG J2323 Natalizumab injection NATALIZUMAB 1 MG J2325 Nesiritide injection Natrecor 0.1 MG J2353 Octreotide injection, depot Sandostatin Lar Depot 1 MG J2355 Oprelvekin injection Neumega 5 MG J2357 Omalizumab injection Xolair 5 MG J2358 Olanzapine long-acting inj ZYPREXA RELPREVV 1 MG J2426 Paliperidone palmitate inj INVEGA SUSTENNA 1 MG J2469 Palonosetron hcl Aloxi 25 MCG J2503 Pegaptanib sodium injection Macugen 0.3 MG J2504 Pegademase bovine, 25 iu Adagen 25 IU J2505 Injection, pegfilgrastim 6mg Neulasta 6 MG J2543 Piperacillin/tazobactam NOVAPLUS ZOSYN GM J2543 Piperacillin/tazobactam Piperacillin Sodium-Tazobactam Sodium GM J2545 Pentamidine non-comp unit Nebupent 300 MG J2562 Plerixafor injection Mozobil (PLERIXAFOR) 1 MG J2597 Inj desmopressin acetate Ddavp 1 MCG J2724 Protein c concentrate CEPROTIN 10 UNITS J2730 Pralidoxime chloride inj Protopam Chloride 1 GM J2770 Quinupristin/dalfopristin Synercid 500 MG J2778 Ranibizumab injection RANIBIZUMAB 0.1 mg J2780 Ranitidine hydrochloride inj Zantac In Nacl 25 MG J2783 Rasburicase Elitek 0.5 MG J2785 Regadenoson injection Regadenoson 0.1 MG J2788 Rho d immune globulin 50 mcg Bayrho-D 50 MCG (250 IU) 300 MCG (1500 J2790 Rho d immune globulin inj HYPERRHO S/D IU) J2791 Rhophylac injection Rhophylac 100 UNITS Outpatient Drugs Payment Policy Page 8 of 13

9 J2792 Rho(D) immune globulin h, sd WINRHO SDF 100 IU J2794 Risperidone, long acting Risperdal Consta 0.5 MG J2795 Ropivacaine HCl injection Naropin 1 MG J2795 Ropivacaine HCl injection Naropin (Novaplus) 1 MG J2796 Romiplostim injection Nplate 10 MCG J2820 Sargramostim injection Leukine 50 MCG J2916 Na ferric gluconate complex Ferrlecit 12.5 MG J2997 Alteplase recombinant Cathflo Activase 1 MG J2997 Alteplase recombinant Activase 1 MG J3070 Pentazocine injection TALWIN LACTATE 30 MG J3095 Telavancin injection VIBATIV 10 MG J3101 Tenecteplase injection TNKASE 1 MG J3240 Thyrotropin injection Thyrogen 0.9 MG J3243 Tigecycline injection Tigecycline 1 MG J3246 Tirofiban HCl Aggrastat 0.25 MG J3262 Tocilizumab injection Actemra 1 MG J3285 Treprostinil injection Remodulin 1 MG J3300 Triamcinolone A inj PRS-free Triamcinolone Acetonide, Preservative Free 1 MG J3315 Triptorelin pamoate Trelstar 3.75 MG J3357 Ustekinumab injection STELARA 1 MG J3385 Velaglucerase alfa VPRIV 100 UNITS J3396 Verteporfin injection Visudyne 0.1 MG J3465 Injection, voriconazole Vfend Iv 10 MG J3471 Ovine, up to 999 USP units Vitrase 1 UNIT J3473 Hyaluronidase recombinant HYALURONIDASE 1 USP UNIT J3486 Ziprasidone mesylate Geodon 10 MG J3487 Zoledronic acid Zometa 1 MG J3488 Reclast injection Reclast 1 MG J7183 Wilate injection WILATE 1 I.U. VWF:RCO J7185 Xyntha inj XYNTHA J7186 Antihemophilic viii/vwf comp Alphanate /von Willebrand Factor Complex J7187 Humate-P, inj HUMATE-P LOW DILUENT J7189 Factor viia Novoseven RT 1 MCG J7190 Factor viii Hemofil M J7190 Factor viii MONOCLATE-P J7190 Factor viii Alphanate /von Willebrand Factor Complex J7192 Factor viii recombinant NOS Advate J7192 Factor viii recombinant NOS HELIXATE FS PER FACTOR VIII IU Outpatient Drugs Payment Policy Page 9 of 13

10 J7192 Factor viii recombinant NOS Helixate FS 3000 J7192 Factor viii recombinant NOS RECOMBINATE J7193 Factor IX non-recombinant Mononine J7193 J7193 J7193 J7194 J7194 J7194 Factor IX non-recombinant Factor IX non-recombinant Factor IX non-recombinant Factor ix complex Factor ix complex Factor ix complex Alphanine SD VF 1000 IU M2V USA Alphanine SD VF 1500 IU M2V USA Alphanine SD VF 500 IU M2V USA Profilnine SD FIX SD M2V(1000) Profilnine SD FIX SD M2V(1500) Profilnine SD FIX SD M2V(500) J7194 Factor ix complex Bebulin J7195 Factor IX recombinant Benefix J7198 Anti-inhibitor FEIBA NF J7309 Methyl aminolevulinate, top METVIXIA 1 GM J7310 Ganciclovir long act implant VITRASERT 4.5 MG J7311 Fluocinolone acetonide implt Fluocinolone acetonide implt (Retisert) Outpatient Drugs Payment Policy Page 10 of MG J7312 Dexamethasone intra implant Ozurdex 0.1 MG J7335 Capsaicin 8% patch Qutenza 10 SQ CM J7504 Lymphocyte immune globulin Atgam 250 MG J7511 Antithymocyte globuln rabbit Thymoglobulin 25 MG J7517 Mycophenolate mofetil oral Cellcept 250 MG J7518 Mycophenolic acid Myfortic 180 MG J7520 Sirolimus, oral Rapamune 1 MG J7525 Tacrolimus injection Prograf 5 MG J7605 Arformoterol non-comp unit ARFORMOTEROL 15 mcg J7606 Formoterol fumarate, inh PERFOROMIST 20 MCG J7612 Levalbuterol non-comp con Xopenex 0.5 MG J7614 Levalbuterol non-comp unit Xopenex 0.5 MG J7639 Dornase alfa non-comp unit Pulmozyme 1 MG J7665 Mannitol for inhaler Aridol 5 MG J7682 Tobramycin non-comp unit TOBI 300 MG J7686 Treprostinil, non-comp unit TYVASO (Refill Kit) 1.74 MG J7686 Treprostinil, non-comp unit TYVASO 1.74 MG J7686 Treprostinil, non-comp unit TYVASO (Starter Kit) 1.74 MG J8501 Oral aprepitant Emend Bi-pack 5 MG J8501 Oral aprepitant Emend 5 MG

11 J8501 Oral aprepitant Emend Tri-Fold 5 MG J8510 Oral busulfan Myleran 2 MG J8520 Capecitabine, oral, 150 mg Xeloda 150 MG J8521 Capecitabine, oral, 500 mg Xeloda 500 MG J8561 Oral everolimus Zortress 0.25 MG J8562 Oral fludarabine phosphate OFORTA 10 MG J8600 Melphalan oral 2 MG Alkeran 2 MG J8700 Temozolomide Temodar 5 MG J8705 Topotecan oral Topotecan, oral 0.25 mg J9010 Alemtuzumab injection Campath 10 MG J9017 Arsenic trioxide injection Trisenox 1 MG J9020 Asparaginase injection Elspar UNITS J9027 Clofarabine injection Clolar 1 MG J9031 Bcg live intravesical vac Tice Bcg 1 EA J9033 Bendamustine injection TREANDA 1 MG J9035 Bevacizumab injection Avastin 10 MG J9041 Bortezomib injection Velcade 0.1 MG J9043 Cabazitaxel injection JEVTANA 1 MG J9050 Carmustine injection BICNU 100 MG J9055 Cetuximab injection Erbitux 10 MG J9120 Dactinomycin injection Cosmegen 0.5 MG J9155 Degarelix injection Firmagon 1 MG J9160 Denileukin diftitox inj Ontak 300 MCG J9171 Docetaxel injection Taxotere 1 MG J9178 Inj, epirubicin hcl, 2 mg Epirubicin 2 MG J9179 Eribulin mesylate injection Halaven 0.1 MG J9181 Etoposide injection Etopophos 10 MG J9185 Fludarabine phosphate inj Fludara 50 MG J9202 Goserelin acetate implant Zoladex 3.6 MG J9207 Ixabepilone injection IXABEPILONE 1 MG J9208 Ifosfamide injection Ifex 1 GM J9209 Mesna injection Mesnex 200 MG J9214 Interferon alfa-2b inj Intron-A 1 MIL UNITS J9217 Leuprolide acetate suspnsion Lupron Depot 7.5 mg kit 7.5 MG J9217 J9217 J9217 Leuprolide acetate suspnsion Leuprolide acetate suspnsion Leuprolide acetate suspnsion LUPRON DEPOT 4-MONTH, 30MG LUPRON DEPOT 6-MONTH, 45MG Lupron Depot-3 month 22.5mg kit 7.5 MG 7.5 MG 7.5 MG J9217 Leuprolide acetate suspnsion Lupron Depot-Ped 15mg 7.5 MG Outpatient Drugs Payment Policy Page 11 of 13

12 J9217 Leuprolide acetate suspnsion Lupron Depot-Ped 7.5mg 7.5 MG J9225 Vantas implant Vantas implant 50 MG J9226 Supprelin LA implant Supprelin LA implant 50 MG J9228 Ipilimumab injection YERVOY 1 MG J9230 Mechlorethamine hcl inj Mustargen 10 MG J9261 Nelarabine injection ARRANON 50 MG J9263 Oxaliplatin Eloxatin 0.5 MG J9266 Pegaspargase injection ONCASPAR 1 EA J9302 Ofatumumab injection ARZERRA 10 MG J9303 Panitumumab injection PANITUMUMAB 10 MG J9305 Pemetrexed injection Alimta 10 MG J9307 Pralatrexate injection Folotyn 1 MG J9310 Rituximab injection Rituxan 100 MG J9315 Romidepsin injection Istodax (romidepsin) 1 MG J9320 Streptozocin injection Zanosar 1 GM J9328 Temozolomide injection TEMODAR IV 1 MG J9330 Temsirolimus injection TEMSIROLIMUS 1 MG J9355 Trastuzumab injection Herceptin 10 MG J9357 Valrubicin injection Valstar 200 MG J9395 Injection, Fulvestrant Faslodex 25 MG Q0138 Ferumoxytol, non-esrd Feraheme 1 MG Q0139 Ferumoxytol, esrd use Feraheme 1 MG Q0180 Dolasetron mesylate oral Anzemet 100 MG Q2017 Teniposide, 50 mg Vumon 50 MG Q2043 Sipuleucel-T auto CD54+ PROVENGE Q2046 Aflibercept injection EYLEA 1 MG Per infusion (minimum 50 million cells) Q2047 Peginesatide injection Omontys 0.1 MG Q2048 Doxil injection Doxil 10 MG Q2049 Imported Lipodox inj Lipodox 10 MG Q2049 Imported Lipodox inj Lipodox MG Q3025 IM inj interferon beta 1-a Avonex 11 MCG Q4074 Iloprost non-comp unit dose Ventavis UP TO 20 MCG Q4081 Epoetin alfa, 100 units ESRD Procrit 100 UNITS Q4081 Epoetin alfa, 100 units ESRD Epogen 100 UNITS Q9956 Inj octafluoropropane mic,ml Optison 1 ML Q9957 Inj perflutren lip micros,ml Definity 1 ML Q9965 LOCM mg/ml iodine,1ml OMNIPAQUE ML Q9965 LOCM mg/ml iodine,1ml Omnipaque ML Q9966 LOCM mg/ml iodine,1ml Visipaque 1 ML Outpatient Drugs Payment Policy Page 12 of 13

13 Q9966 LOCM mg/ml iodine,1ml Omnipaque 1 ML Q9966 LOCM mg/ml iodine,1ml Omnipaque ML Q9966 LOCM mg/ml iodine,1ml Visipaque ML Q9966 LOCM mg/ml iodine,1ml Omnipaque ML Q9967 LOCM mg/ml iodine,1ml Visipaque ML Q9967 LOCM mg/ml iodine,1ml Visipaque 1 ML Q9967 LOCM mg/ml iodine,1ml Omnipaque ML Q9967 LOCM mg/ml iodine,1ml Omnipaque ML Q9967 LOCM mg/ml iodine,1ml Omnipaque 1 ML Outpatient Drugs Payment Policy Page 13 of 13