Unclassified Drugs in excess of $10,000 J3490 Unclassified Biologics in excess of $10,000 J3590 Revenue Codes in excess of $10,000 R250 - R259 ABRAXANE paclitaxel protein-bound J9264 & J9267 ACTEMRA tocilizumab J3262 ACTHAR repository corticotropin J0800 ACTIMMUNE interferon gamma-1b J9216 ADAGEN pegademase bovine J2504 ADCETRIS brentuximab vedotin J9042 ADCIRCA tadalafil oral ADEMPAS riociguat oral ADVATE (All Forms) antihemophilic factor, recombinant J7186 AFINITOR everolimus oral J7527 AFINITOR DISPERZ everolimus oral soluble J7527 ALECENSA alectinib oral ALPHANINE SD factor IX (human) J7193, J7194, J7200, J7201, 77202 AMPYRA dalfampridine (4-aminopyridine) oral APOKYN apomorphine hydrochloride J0364 ARCALYST rilonacept J2793 ATRIPLA efavirenz/emtricitabine/tenofovir disoproxil fumarate oral AUBAGIO teriflunomide oral AVASTIN bevacizumab J9035 AVONEX interferon beta-1a J1826 & Q3027 AVONEX PEN KIT interferon beta-1a J1826 & Q3027 BENEFIX factor IX (recombinant) J7195 BENLYSTA belimumab J0490 BERINERT C1 inhibitor, human BETASERON interferon beta-1b J1830 BETHKIS tobramycin oral inhalation J7682 & J7685 BICNU carmustine (BCNU) J9050 BLINCYTO blinatumomab J9039 BOSULIF bosutinib oral BRAVELLE urofollitropin J3355 Page 1 of 7 7/5/2017
CAPRELSA vandetanib oral CARIMUNE NF intravenous CAYSTON aztreonam inhalation CEREZYME imiglucerase CETROTIDE cetrorelix acetate CIMZIA certolizumab pegol CIMZIA PREFL KIT certolizumab pegol J0717 & J0718 CINQAIR reslizumab CINRYZE C1 inhibitor, human COMETRIQ cabozantinib malate oral COMPLERA emtricitabine/rilpivirine hydrochloride/tenofovir disoproxil fumarate oral COPAXONE* glatiramer acetate J1595 Corlanor ivabradine oral COSENTYX secukinumab COSENTYX PEN INJ secukinumab COTELLIC cobimetinib fumarate oral DAKLINZA daclatasvir dihydrochloride oral ELAPRASE idursulfase J1743 ELOCTATE antihemophilic factor, recombinant (Fc Fusion Protein) J7186 ENBREL SRCLK* etanercept J1438 ENBREL* etanercept J1438 Enstilar calcipotriene/betamethasone dipropionate topical ENTYVIO* vedolizumab J3380 EPCLUSA sofosbuvir/velpatasvir oral EPOGEN epoetin alfa recombinant (erythropoietin; EPO) J0885 & J0886 ERIVEDGE vismodegib oral ESBRIET pirfenidone oral Evzio naloxone hydrochloride J2310 EXJADE deferasirox oral EXTAVIA interferon beta-1b J1830 EYLEA aflibercept ophthalmic J0178 FABRAZYME agalsidase beta J0180 Page 2 of 7 7/5/2017
FARYDAK panobinostat lactate oral Femara (brand only) Brand Only - generic is letrozole oral FIRAZYR icatibant acetate J1744 FORTEO teriparatide J3110 FUZEON enfuvirtide J1324 GAMMAGARD GAMMAGARD SD GAMUNEX GAMUNEX C GAZYVA obinutuzumab J9301 GENVOYA elvitegravir/cobicistat/emtricitabine/tenofo vir alafenamide fumarate oral GILENYA fingolimod hydrochloride oral GLATOPA glatiramer acetate J1595 & J7199 GLEEVEC imatinib mesylate oral S0088 HARVONI ledipasvir/sofosbuvir oral HELIXATE FS antihemophilic factor, recombinant J7186 HERCEPTIN trastuzumab J9355 HIZENTRA* subcutaneous HUMATE-P antihemophilic factor/von willebrand factor complex (factor VIII/VWF; AHF/VWF) J7186 HUMATROPE somatropin J2941 HUMIRA adalimumab J0135 HUMIRA PEN adalimumab J0135 HYCAMTIN topotecan hydrochloride /oral J8705 & J9351 HYQVIA /hyaluronidase subcutaneous & J3470 IBRANCE palbociclib oral ILARIS canakinumab J0638 ILUVIEN fluocinolone acetonide ophthalmic J7313 Page 3 of 7 7/5/2017
Imatinib (generic Gleevec) imatinib mesylate oral S0088 IMBRUVICA ibrutinib oral IMLYGIC talimogene laherparepvec J9325 INCIVEK telaprevir oral INLYTA axitinib oral INTELENCE etravirine oral ISENTRESS raltegravir potassium oral Jadenu deferasirox oral JAKAFI ruxolitinib phosphate oral KADCYLA ado-trastuzumab emtansine J9354 KALETRA lopinavir/ritonavir oral KALYDECO ivacaftor oral KYPROLIS carfilzomib J9047 LEMTRADA alemtuzumab J0202 & J9010 LETAIRIS ambrisentan oral LONSURF trifluridine/tipiracil hydrochloride oral LUCENTIS ranibizumab intravitreal J2778 LYNPARZA olaparib oral MAKENA hydroxyprogesterone caproate J1725 MATULANE procarbazine hydrochloride (N- Methylhydrazine; MIH) oral S0182 MEKINIST trametinib dimethyl sulfoxide oral NEORAL cyclosporine (cyclosporin A) oral J7502 & J7515 NEULASTA pegfilgrastim J2505 NEUPOGEN filgrastim (granulocyte colony-stimulating J1440, J1441, J1442, factor; G-CSF) J1446, J1447 NEXAVAR sorafenib tosylate oral NINLARO ixazomib oral NORDITROPIN (ALL FORMS)* somatropin J2941 NORTHERA droxidopa oral NPLATE romiplostim J2796 NUCALA mepolizumab J2182 NUTROPIN (ALL FORMS)* somatropin J2941 Nutropin Nuspin AQ* somatropin J2941 OCALIVA obeticholic acid oral OCREVUS ocrelizumab Page 4 of 7 7/5/2017
ODEFSEY emtricitabine/rilpivirine hydrochloride/tenofovir alafenamide fumarate oral ODOMZO sonidegib oral OFEV nintedanib ethanesulfonate oral OLYSIO simeprevir sodium oral OPDIVO nivolumab J9299 OPSUMIT macitentan oral ORENCIA abatacept J0129 ORENCIA-C abatacept J0129 ORENITRAM treprostinil diolamine oral J3285 & J7686 ORKAMBI lumacaftor/ivacaftor oral OTEZLA apremilast oral PEG-INTRON peginterferon alfa-2b S0148 PERJETA pertuzumab J9306 Pertzye digestive enzymes oral PLEGRIDY peginterferon beta-1a POMALYST pomalidomide oral PREZCOBIX darunavir/cobicistat oral PREZISTA darunavir ethanolate oral PRIVIGEN intravenous PROLIA denosumab J0897 PROMACTA eltrombopag olamine oral PULMOZYME dornase alfa (recombinant human deoxyribonuclease; rhdnase) inhalation J7639 RAVICTI glycerol phenylbutyrate oral Rayos prednisone oral J7506 & J7512 REBIF interferon beta-1a J1826 & Q3026 & Q3028 REBIF REBIDO interferon beta-1a J1826 & Q3026 & Q3028 REBIF TITRTN INJ PACK interferon beta-1a J1826 & Q3026 & Q3028 RELISTOR methylnaltrexone bromide oral J2212 REMICADE (Inflectra is biosimilar to Remicade) infliximab J1745 REMODULIN treprostinil sodium J3285 & J7686 REPATHA (all 3 versions) evolocumab REVATIO sildenafil citrate /oral REVLIMID lenalidomide oral REYATAZ atazanavir sulfate oral Page 5 of 7 7/5/2017
RIBAVIRIN ribavirin oral/inhalation RITUXAN rituximab J9310 SABRIL vigabatrin oral SANDIMMUNE cyclosporine (cyclosporin A) oral/ J7502 & J7515 SANDOSTATIN octreotide acetate J2353 & J2354 SENSIPAR cinacalcet hydrochloride oral SIMPONI golimumab J1602 SOMAVERT pegvisomant SOVALDI sofosbuvir oral SPINRAZA nusinersen SPRYCEL dasatinib oral STELARA ustekinumab J3357 STIVARGA regorafenib oral STRIBILD elvitegravir/cobicistat/emtricitabine/tenofo vir disoproxil fumarate oral SUCRAID sacrosidase oral SUPPRELIN LA* histrelin acetate subcutaneous SUTENT sunitinib malate oral Syprine trientine hydrochloride oral TAFINLAR dabrafenib mesylate oral TALTZ ixekizumab TARCEVA erlotinib hydrochloride oral TASIGNA nilotinib hydrochloride oral TECENTRIQ atezolizumab 9999, J3590, J3490, C948 TECFIDERA* dimethyl fumarate oral THALOMID thalidomide oral THYROGEN thyrotropin alfa J3240 TIVICAY dolutegravir sodium oral TOBI tobramycin oral inhalation J7682 TOBI PODHALR tobramycin oral inhalation J7682 Tobramycin inhaled (generic Tobi) tobramycin oral inhalation J7682 Topotecan (generic Hycamtin) topotecan hydrochloride /oral J8705 & J9351 TRIUMEQ abacavir sulfate/dolutegravir sodium/lamivudine oral TYKERB lapatinib ditosylate oral TYSABRI natalizumab J2323 Page 6 of 7 7/5/2017
TYVASO treprostinil inhalation J3285 & J7686 VECTIBIX panitumumab J9303 VELCADE bortezomib J9041 VENCLEXTA venetoclax oral Viberzi eluxadoline oral VIEKIRA ombitasvir/paritaprevir/ritonavir/dasabuvir sodium oral VIREAD tenofovir disoproxil fumarate oral Vivaglobin VIVITROL naltrexone J2315 VOTRIENT pazopanib hydrochloride oral VPRIV velaglucerase alfa J3385 VRAYLAR cariprazine oral XALKORI crizotinib oral XELJANZ tofacitinib citrate oral XENAZINE tetrabenazine oral XGEVA denosumab J0897 XIAFLEX collagenase clostridium histolyticum J0775 Xifaxan* rifaximin oral XOLAIR omalizumab J2357 XTANDI enzalutamide oral XYREM sodium oxybate oral ZELBORAF vemurafenib oral ZEMAIRA alpha 1-proteinase inhibitor, human (alpha 1-antitrypsin) J0256 ZEPATIER elbasvir/grazoprevir oral ZOLADEX goserelin acetate implant J9202 ZORTRESS everolimus oral J7527 ZYDELIG idelalisib oral ZYKADIA ceritinib oral ZYTIGA abiraterone acetate oral Page 7 of 7 7/5/2017