Highmark List of Procedure Codes Requiring NDC Effective 12/01/2017

Transcription

1 90378 RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINANT, FOR INTRAMUSCULAR USE, 50 MG, EACH C9399 Unclassified Drugs or biologicals J0129 INJECTION, ABATACEPT, 10 MG J0130 INJECTION ABCIXIMAB, 10 MG J0131 INJECTION, ACETAMINOPHEN, 10 MG J0132 INJECTION, ACETYLCYSTEINE, 100 MG J0133 INJECTION, ACYCLOVIR, 5 MG J0135 INJECTION, ADALIMUMAB, 20 MG J0153 INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS) J0178 INJECTION, AFLIBERCEPT, 1 MG J0180 INJECTION, AGALSIDASE BETA, 1MG J0207 INJECTION, AMIFOSTINE, 500 MG J0210 INJECTION, METHYLDOPATE HCL, UP TO 250 MG J0220 INJECTION, ALGLUCOSIDASE ALFA, 10 MG, NOT OTHERWISE CLASSIFIED J0221 INJECTION, ALGLUCOSIDASE ALFA, (LUMIZYME), 10 MG J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), NOT OTHERWISE SPECIFIED, 10 MG J0257 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 MG J0285 INJECTION, AMPHOTERICIN B, 50 MG J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG J0289 INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG J0295 INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM J0348 INJECTION, ANIDULAFUNGIN, 1 MG J0364 INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG J0401 INJECTION, ARIPIPRAZOLE, EXTENDED RELEASE, 1 MG J0456 INJECTION, AZITHROMYCIN, 500 MG J0470 INJECTION, DIMERCAPROL, PER 100 MG J0475 INJECTION, BACLOFEN, 10 MG J0476 INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL J0480 INJECTION, BASILIXIMAB, 20 MG J0485 INJECTION, BELATACEPT, 1 MG J0490 INJECTION, BELIMUMAB, 10 MG J0558 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, 100,000 UNITS J0561 INJECTION, PENICILLIN G BENZATHINE 100,000 UNITS J0571 BUPRENORPHINE, ORAL, 1 MG J0572 BUPRENORPHINE/NALOXONE, ORAL, LESS THAN OR EQUAL TO 3 MG BUPRENORPHINE J0573 BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 3 MG, BUT LESS THAN OR EQUAL TO 3.1 TO 6 MG 1

2 J0574 J0575 J0583 J0585 J0586 J0587 J0588 J0592 J0594 J0596 J0597 J0598 J0600 J0630 J0636 J0637 J0638 J0641 J0670 J0695 J0697 J0698 J0702 J0706 J0712 J0713 J0714 J0717 J0720 J0735 J0740 J0743 J0770 J0775 J0795 J0800 J0833 BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 10 MG BUPRENORPHINE INJECTION, BIVALIRUDIN, 1 MG INJECTION, ONABOTULINUMTOXINA, 1 UNIT INJECTION, ABOBOTULINUMTOXINA, 5 UNITS INJECTION, RIMABOTULINUMTOXINB, 100 UNITS INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUSULFAN, 1 MG INJECTION, C1 ESTERASE INHIBITOR (RECOMBINANT), RUCONEST, 10 UNITS INJECTION, C1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, CALCITONIN SALMON, UP TO 400 UNITS INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CASPOFUNGIN ACETATE, 5 MG INJECTION, CANAKINUMAB, 1 MG INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, CEFTOLOZANE 50 MG AND TAZOBACTAM 25 MG INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG INJECTION, CAFFEINE CITRATE, 5 MG INJECTION, CEFTAROLINE FOSAMIL, 10 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME AND AVIBACTAM, 0.5 G/0.125 G 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, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION CIDOFOVIR, 375 MG INJECTION, CILASTATIN SODIUM, IMIPENEM, PER 250 MG INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG INJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAM INJECTION, CORTICOTROPIN, UP TO 40 UNITS INJECTION, COSYNTROPIN, NOT OTHERWISE SPECIFIED, 0.25 MG 2

3 J0834 J0840 J0850 J0875 J0878 J0881 J0882 J0885 J0894 J0895 J0897 J1000 J1020 J1030 J1040 J1050 J1071 J1110 J1160 J1162 J1165 J1190 J1205 J1212 J1230 J1260 J1267 J1270 J1290 J1300 J1322 J1324 J1325 J1327 J1335 J1364 J1380 J1410 J1430 INJECTION, COSYNTROPIN (CORTROSYN), 0.25 MG INJECTION, CROTALIDAE POLYVALENT IMMUNE FAB (OVINE), UP TO 1 GRAM INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL INJECTION, DALBAVANCIN, 5MG INJECTION, DAPTOMYCIN, 1 MG 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, DECITABINE, 1 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DENOSUMAB, 1 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE. 80 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG INJECTION, TESTOSTERONE CYPIONATE, 1MG INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG INJECTION, DIGOXIN, UP TO 0.5 MG INJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIAL INJECTION, PHENYTOIN SODIUM, PER 50 MG INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, DORIPENEM, 10 MG INJECTION, DOXERCALCIFEROL, 1 MCG INJECTION, ECALLANTIDE, 1 MG INJECTION, ECULIZUMAB, 10 MG INJECTION, ELOSULFASE ALFA, 1MG INJECTION, ENFUVIRTIDE, 1 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPTIFIBATIDE, 5 MG INJECTION, ERTAPENEM SODIUM, 500 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ESTRADIOL VALERATE, UP TO 10 MG INJECTION, ESTROGEN CONJUGATED, PER 25 MG INJECTION, ETHANOLAMINE OLEATE, 100 MG 3

4 J1438 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) INJECTION, FERRIC CARBOXYMALTOSE, 1MG INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION, 0.1 MG OF IRON INJECTION, TBO-FILGRASTIM, 1 MICROGRAM INJECTION FLUCONAZOLE, 200 MG INJECTION, FOMEPIZOLE, 15 MG INJECTION, FOSAPREPITANT, 1 MG INJECTION, FOSCARNET SODIUM, PER 1000 MG INJECTION, GALSULFASE, 1 MG INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MG J1439 J1442 J1443 J1447 J1450 J1451 J1453 J1455 J1458 J1459 J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG J1557 INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MG J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG J1561 INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E. G.LIQUID), 500 MG J1566 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G., POWDER), NOT OTHERWISE SPECIFIED, 500 MG J1568 INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E.G., LIQUID), 500 MG J1572 J1575 J1595 J1602 J1630 J1631 J1640 J1645 J1650 J1652 J1670 J1700 J1720 J1725 J1740 J1741 J1742 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NON- LYOPHILIZED (E.G. LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE INJECTION, HALOPERIDOL, UP TO 5MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HEMIN, 1 MG INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG INJECTION, HYDROXYPROGESTERONE CAPROATE, 1 MG INJECTION, IBANDRONATE SODIUM, 1 MG INJECTION, IBUPROFEN, 100 MG INJECTION, IBUTILIDE FUMARATE, 1 MG 4

5 J1743 J1744 J1745 J1750 J1756 J1786 J1790 J1800 J1815 J1817 J1826 J1830 INJECTION, IDURSULFASE, 1 MG INJECTION, ICATIBANT, 1 MG INJECTION INFLIXIMAB, 10 MG INJECTION, IRON DEXTRAN, 50 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, IMIGLUCERASE, 10 UNITS INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, PROPRANOLOL HCL, UP TO 1 MG INJECTION, INSULIN, PER 5 UNITS INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 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, ISAVUCONAZONIUM, 1 MG INJECTION, LANREOTIDE, 1 MG INJECTION, LARONIDASE, 0.1 MG INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG INJECTION, LEVETIRACETAM, 10 MG INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOFLOXACIN, 250 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, LINCOMYCIN HCL, UP TO 300 MG INJECTION, LINEZOLID, 200MG INJECTION, MECASERMIN, 1 MG INJECTION, MEROPENEM, 100 MG INJECTION, METHYLNALTREXONE, 0. 1 MG INJECTION, MICAFUNGIN SODIUM, 1 MG INJECTION, MINOCYCLINE HYDROCHLORIDE, 1 MG INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, MOXIFLOXACIN, 100 MG INJECTION, NALTREXONE, DEPOT FORM, 1 MG INJECTION, NATALIZUMAB, 1 MG INJECTION, NESIRITIDE, 0.1 MG J1833 J1930 J1931 J1950 J1953 J1955 J1956 J1980 J2010 J2020 J2170 J2185 J2212 J2248 J2265 J2278 J2280 J2315 J2323 J2325 J2353 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG J2354 INJECTION, OCTREOTIDE, ON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG J2357 INJECTION, OMALIZUMAB, 5 MG J2358 INJECTION, OLANZAPINE, LONG-ACTING, 1 MG J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML 5

6 J2407 J2410 J2425 J2426 J2440 J2469 J2501 J2502 J2503 J2504 J2505 J2507 J2510 J2515 J2540 J2543 J2545 INJECTION, ORITAVANCIN, 10 MG INJECTION, OXYMORPHONE HCL, UP TO 1 MG INJECTION, PALIFERMIN, 50 MICROGRAMS INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, 1MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PALONOSETRON HCL, 25 MCG INJECTION, PARICALCITOL, 1 MCG INJECTION, PASIREOTIDE LONG ACTING, 1 MG INJECTION, PEGAPTANIB SODIUM, 0.3 MG INJECTION, PEGADEMASE BOVINE, 25 IU INJECTION, PEGFILGRASTIM, 6 MG INJECTION, PEGLOTICASE, 1 MG INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS INJECTION, PENTOBARBITAL SODIUM, PER 50 MG INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS (1.125 GRAMS) PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON- COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG INJECTION, PERAMIVIR, 1 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PLERIXAFOR, 1 MG INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PROGESTERONE, PER 50 MG INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG INJECTION, PROCAINAMIDE HCL, UP TO 1 GM INJECTION, OXACILLIN SODIUM, UP TO 250 MG INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM J2547 J2560 J2562 J2650 J2675 J2680 J2690 J2700 J2724 J2730 J2760 INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG J2770 INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350) J2778 INJECTION, RANIBIZUMAB, 0.1 MG J2780 INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG J2783 INJECTION, RASBURICASE, 0.5 MG J2785 INJECTION, REGADENOSON, 0.1 MG J2788 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MCG J2790 INJECTION, RHO (D) IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG J2791 J2792 J2793 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 6

7 J2794 J2796 J2800 J2805 J2810 J2820 J2850 J2860 J2916 J2930 J2941 J2997 J3000 J3060 J3070 J3090 J3095 J3101 J3110 J3121 J3145 J3230 J3240 J3243 J3246 J3250 J3262 J3285 J3300 J3301 J3302 J3303 J3315 J3355 J3357 J3380 J3385 J3396 J3430 INJECTION, RISPERIDONE, LONG ACTING, 0.5MG INJECTION, ROMIPLOSTIM, 10 MICROGRAMS INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, SINCALIDE, 5 MICROGRAMS INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAM INJECTION, SILTUXIMAB, 10 MG INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, SOMATROPIN, 1MG INJECTION, ALTEPLASE RECOMBINANT, 1 MG INJECTION, STREPTOMYCIN, UP TO 1 GM INJECTION, TALIGLUCERACE ALFA, 10 UNITS INJECTION, PENTAZOCINE, 30 MG INJECTION, TEDIZOLID PHOSPHATE, 1 MG INJECTION, TELEVANCIN, 10MG INJECTION, TENECTEPLASE, 1 MG INJECTION, TERIPARATIDE, 10 MCG INJECTION, TESTOSTERONE ENANTHATE, 1MG INJECTION, TESTOSTERONE UNDECANOATE, 1 MG INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, THYROTROPIN ALFA, 0.9 MG, PROVIDED IN 1.1 MG VIAL INJECTION, TIGECYCLINE, 1 MG INJECTION, TIROFIBAN, 0.25 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TOCILIZUMAB, 1 MG INJECTION, TREPROSTINIL, 1 MG INJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE FREE, 1 MG INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG INJECTION TRIAMCINOLONE DIACETATE, PER 5MG INJECTION TRIAMCINOLONE HEXACETONIDE, PER 5MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, UROFOLLITROPIN, 75 IU INJECTION, USTEKINUMAB, 1 MG INJECTION, VEDOLIZUMAB, 1 MG INJECTION, VELAGLUCERASE ALFA, 100 UNITS INJECTION, VERTEPORFIN, 0.1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG 7

8 J3465 J3470 J3471 J3485 J3486 J3489 J3490 J3590 J7070 J7100 J7131 J7178 J7180 J7181 J7182 J7183 J7185 J7186 INJECTION, VORICONAZOLE, 10 MG INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1 USP UNIT (UP TO 999 USP UNITS) INJECTION, ZIDOVUDINE, 10 MG INJECTION, ZIPRASIDONE MESYLATE, 10 MG INJECTION, ZOLEDRONIC ACID, 1 MG Unclassified Drugs Unclassified Biologics INFUSION, D5W, 1000 CC INFUSION, DEXTRAN 40, 500 ML HYPERTONIC SALINE SOLUTION, 1 ML INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 1 MG 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 IU INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (OBIZUR), PER I.U. FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) 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. INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), RIXUBIS, PER IU INJECTION, FACTOR IX, FC FUSION PROTEIN (RECOMBINANT), PER IU INJECTION, FACTOR VIII FC FUSION (RECOMBINANT), PER IU J7187 J7188 J7189 J7190 J7192 J7193 J7194 J7195 J7197 J7198 J7200 J7201 J7205 J7303 CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACH J7308 AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SINGLE UNIT DOSAGE FORM (354 MG) J7309 METHYL AMINOLEVULINATE (MAL) FOR TOPICAL ADMINISTRATION, 16.8%, 1 GRAM J7311 FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT J7312 INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MG J7316 INJECTION, OCRIPLASMIN, MG J7321 HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR INJECTION, PER DOSE 8

9 J7323 J7324 J7325 J7326 J7327 J7336 J7340 J7500 J7502 J7503 J7504 J7507 J7508 J7509 J7510 J7511 J7515 J7516 J7517 J7518 J7520 J7525 J7527 J7599 J7605 J7606 J7608 J7612 J7614 J7626 J7631 J7639 J7665 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, GEL-ONE, FOR INTRA-ARTICULAR INJECTION, PER DOSE HYALURONAN OR DERIVATIVE, MONOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER CARBIDOPA 5 MG/LEVODOPA 20 MG ENTERAL SUSPENSION AZATHIOPRINE, ORAL, 50 MG CYCLOSPORINE, ORAL, 100 MG TACROLIMUS, EXTENDED RELEASE, (ENVARSUS XR), ORAL, 0.25 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MG TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG TACROLIMUS, EXTENDED RELEASE, (ASTAGRAF XL), ORAL, 0.1 MG METHYLPREDNISOLONE ORAL, PER 4 MG PREDNISOLONE ORAL, PER 5 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORIN, PARENTERAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLIC ACID, ORAL, 180 MG SIROLIMUS, ORAL, 1 MG TACROLIMUS, PARENTERAL, 5 MG EVEROLIMUS, ORAL, MG Immunosuppressive Drug, Not Otherwise Classified 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 ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUND ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM MANNITOL, ADMINISTERED THROUGH AN INHALER, 5 MG 9

10 J7674 METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION THROUGH A NEBULIZER, PER 1 MG J7682 TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300 MILLIGRAMS J7686 TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MG J7699 NOC Drugs, Inhalation Solution Administered Through DME J7799 NOC Drugs, Other Than Inhalation Drugs Administered Through DME J8499 Prescription Drug, Oral, Non Chemotherapeutic, NOS J8501 APREPITANT, ORAL, 5 MG J8510 BUSULFAN; ORAL, 2 MG J8515 CABERGOLINE, ORAL, 0.25 MG J8520 CAPECITABINE, ORAL, 150 MG J8521 CAPECITABINE, ORAL, 500 MG J8530 CYCLOPHOSPHAMIDE; ORAL, 25 MG (PER TABLET) J8560 ETOPOSIDE; ORAL, 50 MG (PER TABLET) J8565 GEFITNIB, ORAL, 250 MG J8597 Antiemetic Drug, Oral, Not Otherwise Specified J8600 MELPHALAN; ORAL, 2 MG J8610 METHOTREXATE; ORAL, 2.5 MG J8650 NABILONE, ORAL, 1 MG J8655 NETUPITANT 300 MG AND PALONOSETRON 0.5 MG J8700 TEMOZOLMIDE, ORAL, 5 MG J8705 TOPOTECAN, ORAL, 0.25 MG J8999 Prescription Drug, Oral, Chemotherapeutic, NOS J9000 DOXORUBICIN HCL, 10 MG J9015 INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL J9017 ARSENIC TRIOXIDE, 1MG J9019 INJECTION, ASPARAGINASE (ERWINAZE), 1,000 IU J9027 INJECTION, CLOFARABINE, 1 MG J9031 BCG (INTRAVESICAL) PER INSTALLATION J9032 INJECTION, BELINOSTAT, 10 MG J9033 INJECTION, BENDAMUSTINE HCL, 1 MG J9035 INJECTION, BEVACIZUMAB 10 MG J9039 INJECTION, BLINATUMOMAB, 1 MICROGRAM J9041 INJECTION, BORTEZOMIB, 0.1 MG J9042 INJECTION, BRENTUXIMAB VEDOTIN, 1 MG J9043 INJECTION, CABAZITAXEL, 1 MG J9047 INJECTION, CARFILZOMIB, 1 MG J9050 INJECTION, CARMUSTINE, 100 MG 10

11 J9055 J9065 J9098 J9100 J9120 J9130 J9150 J9151 J9155 J9171 J9175 J9178 J9179 J9200 J9201 J9202 J9206 J9207 J9208 J9209 J9211 J9214 J9215 J9216 J9217 J9218 J9225 J9226 J9228 J9230 J9245 J9261 J9262 J9263 J9264 J9266 J9268 J9271 J9293 INJECTION, CETUXIMAB, 10 MG INJECTION, CLADRIBINE, PER 1 MG INJECTION, CYTARABINE LIPOSOME, 10 MG INJECTION, CYTARABINE, 100 MG. DACTINOMYCIN, 0.5 MG DACARBAZINE, 100 MG INJECTION, DAUNORUBICIN, 10 MG DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG INJECTION, DEGARELIX, 1 MG INJECTION, DOCETAXEL, 1 MG INJECTION, ELLIOTTS' B SOLUTION, 1 ML INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, ERIBULIN MESYLATE, 0.1 MG INJECTION, FLOXURIDINE, 500 MG INJECTION, GEMCITABINE HCL, 200 MG GOSERELIN ACETATE IMPLANT, PER 3.6 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IXABEPILONE, 1 MG INJECTION, IFOSFAMIDE, 1 GM MESNA, 200 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU 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, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG INJECTION, NELARABINE, 50 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 PENTOSTATIN, PER 10 MG INJECTION, PEMBROLIZUMAB, 1 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG 11

12 J9299 J9301 J9302 J9303 J9305 J9306 J9307 J9308 J9310 J9315 J9320 J9328 J9330 J9340 J9351 J9354 J9355 J9357 J9371 J9390 J9395 J9400 J9600 J9999 Q0138 Q0139 Q0166 Q0167 Q0180 Q2009 Q2017 Q2043 Q2049 INJECTION, NIVOLUMAB, 1 MG INJECTION, OBINUTUZUMAB, 10 MG INJECTION, OFATUMUMAB, 10 MG INJECTION, PANITUMUMAB, 10 MG INJECTION, PEMETREXED, 10 MG INJECTION, PERTUZUMAB, 1 MG INJECTION, PARLATREXATE, 1MG INJECTION, RAMUCIRUMAB, 5 MG INJECTION, RITUXIMAB, 100 MG INJECTION, ROMIDEPSIN, 1MG STREPTOZOCIN, 1 GM INJECTION, TEMOZOLOMIDE, 1 MG INJECTION, TEMSIROLIMUS, 1 MG INJECTION, THIOTEPA, 15 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 VINORELBINE TARTRATE, PER 10 MG INJECTION, FULVESTRANT, 25 MG INJECTION, ZIV-AFLIBERCEPT, 1 MG INJECTION, PORFIMER SODIUM, 75 MG Not Otherwise Classified, Antineoplastic Drug INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE) INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (FOR ESRD ON DIALYSIS) GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANIT-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24-HOUR DOSAGE REGIMEN DRONABINOL 2.5 MG, ORAL, FDA APPROVED 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 DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANIT-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, TENIPOSIDE, 50 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 12

13 Q2050 Q3027 Q3028 Q4074 Q5101 Q5102 Q9957 Q9985 Q9986 Q9989 S0032 S0073 S0104 S0106 S0108 S0109 S0122 S0126 S0128 S0132 S0136 S0137 S0138 S0139 S0140 S0145 S0148 S0155 S0157 S0160 S0166 S0170 S0171 S0172 S0174 S0175 S0176 S0178 INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWISE SPECIFIED, 10MG INJECTION, INTERFERON BETA-1A, 1 MCG FOR INTRAMUSCULAR USE INJECTION, INTERFERON BETA-1A, 1 MCG FOR SUBCUTANEOUS USE ILOPROST, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMS INJECTION, FILGRASTIM (G-CSF), BIOSIMILAR, 1 MICROGRAM INJECTION, INFLIXIMAB, BIOSIMILAR, 10 MG INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML INJECTION, HYDROXYPROGESTERONE CAPROATE, NOT OTHERWISE SPECIFIED, 10 MG INJECTION, HYDROXYPROGESTERONE CAPROATE (MAKENA), 10 MG USTEKINUMAB, FOR INTRAVENOUS INJECTION, 1 MG INJECTION, NAFCILLIN SODIUM, 2 GRAMS INJECTION, AZTREONAM, 500 MG ZIODVUDINE, ORAL, 100MG BUPROPION HCL SUSTAINED RELEASE TABLET, 150 MG, PER BOTTLE OF 60 TABLETS MERCAPTOPURINE, ORAL, 50 MG METHADONE, ORAL 5 MG INJECTION, MENOTROPINS, 75 IU INJECTION, FOLLITROPIN ALFA, 75 IU INJECTION, FOLLITROPIN BETA, 75 IU INJECTION, GANIRELIX ACETATE, 250 MCG CLOZAPINE, 25 MG DIDANOSINE (DDI), 25 MG FINASTERIDE, 5 MG MINOXIDIL, 10 MG SAQUINAVIR, 200 MG INJECTION, PEGYLATED INTERFERON ALFA-2A INJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCG STERILE DILUTANT FOR EPOPROSTENOL, 50ML BECAPLERMIN GEL 0.01%, 0.5 GM DEXTROAMPHETAMINE SULFATE, 5 MG INJECTION, OLANZAPINE, 2.5 MG ANASTROZOLE, ORAL, 1MG INJECTION, BUMETANIDE, 0.5MG CHLORAMBUCIL, ORAL, 2MG DOLASETRON MESYLATE, ORAL 50MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE STATUTE, USE Q0180) FLUTAMIDE, ORAL 125MG HYDROXYUREA, ORAL, 500MG LOMUSTINE, ORAL, 10MG 13

14 S0179 S0182 S0183 S0187 S0189 S0190 S5550 S5551 S5552 S5553 S5561 MEGESTROL ACETATE, ORAL 20MG PROCARBAZINE HYDROCHLORIDE, ORAL, 50MG PROCHLORPERAZINE MALEATE, ORAL, 5MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE STATUTE, USE Q0164) TOMOXIFEN CITRATE, ORAL, 10MG TESTOSTERONE PELLET, 75MG MIFEPRISTONE, ORAL, 200 MG INSULIN, RAPID ONSET; 5 UNITS INSULIN, MOST RAPID ONSET (LISPRO OR ASPART); 5 UNITS INSULIN, INTERMEDIATE ACTING (NPH OR LENTE); 5 UNITS INSULIN, LONG ACTING; 5 UNITS INSULIN DELIVERY DEVICE, REUSABLE PEN; 3 ML SIZE 14