PA List 2021 for Part B
Drug Code | Action | Effective Date (if available) | Drug Description |
|---|---|---|---|
C9050 |
|
| INJECTION, EMAPALUMAB-LZSG, 1 MG |
C9122 |
|
| MOMETASONE FUROATE SINUS IMPLANT 10 MCG SINUVA |
J0129 |
|
| ABATACEPT INJECTION |
J0178 |
|
| AFLIBERCEPT INJECTION |
J0570 |
|
| BUPRENORPHINE IMPLANT 74.2MG |
J0585 |
|
| INJECTION,ONABOTULINUMTOXINA |
J0717 |
|
| CERTOLIZUMAB PEGOL INJ 1MG |
J0718 |
|
| CERTOLIZUMAB PEGOL INJ |
J0791 |
|
| INJECTION CRIZANLIZUMAB-TMCA 5 MG |
J0800 |
|
| INJECTION, CORTICOTROPIN, UP TO 40 UNITS |
J0896 |
|
| INJECTION LUSPATERCEPT-AAMT 0.25 MG |
J0897 |
|
| DENOSUMAB INJECTION |
J1300 |
|
| ECULIZUMAB INJECTION |
J1428 |
|
| INJECTION ETEPLIRSEN 10 MG |
J1429 |
|
| INJECTION GOLODIRSEN 10 MG |
J1442 |
|
| INJ FILGRASTIM EXCL BIOSIMIL |
J1447 |
|
| INJECTION, TBO-FILGRASTIM, 1 MICROGRAM |
J1459 |
|
| INJ IVIG PRIVIGEN 500 MG |
J1555 |
|
| INJECTION IMMUNE GLOBULIN 100 MG |
J1556 |
|
| INJ, IMM GLOB BIVIGAM, 500MG |
J1557 |
|
| GAMMAPLEX INJECTION |
J1558 |
|
| INJECTION IMMUNE GLOBULIN XEMBIFY 100 MG |
J1559 |
|
| HIZENTRA INJECTION |
J1561 |
|
| GAMUNEX-C/GAMMAKED |
J1562 |
|
| INJECTION; IMMUNE GLOBULIN 10%, 5 GRAMS |
J1566 |
|
| INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P |
J1568 |
|
| OCTAGAM INJECTION |
J1569 |
|
| GAMMAGARD LIQUID INJECTION |
J1572 |
|
| FLEBOGAMMA INJECTION |
J1575 |
|
| INJ IG/HYALURONIDASE 100 MG IG |
J1599 |
|
| IVIG NON-LYOPHILIZED, NOS |
J1602 |
|
| GOLIMUMAB FOR IV USE 1MG |
J1745 |
|
| INJ INFLIXIMAB EXCL BIOSIMILR 10 MG |
J1930 | Remove | 1/1/2021 | INJECTION, LANREOTIDE, 1 MG |
J2323 |
|
| NATALIZUMAB INJECTION |
J2350 |
|
| INJECTION OCRELIZUMAB 1 MG |
J2353 | Removed | 1/1/2021 | INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG |
J2357 |
|
| INJECTION, OMALIZUMAB, 5 MG |
J2503 |
|
| INJECTION, PEGAPTANIB SODIUM, 0.3 MG |
J2505 |
|
| INJECTION, PEGFILGRASTIM, 6 MG |
J2507 |
|
| PEGLOTICASE INJECTION |
J2778 |
|
| RANIBIZUMAB INJECTION |
J2786 |
|
| INJECTION RESLIZUMAB 1MG |
J2796 |
|
| ROMIPLOSTIM INJECTION |
J2820 |
|
| INJECTION, SARGRAMOSTIM (CM-CSF), 50 MCG |
J3111 | Added | 1/1/2021 | INJECTION ROMOSOZUMAB-AQQG 1 MG |
J3304 |
|
| INJECT TRIAMCINOLONE ACETONIDE PF ER MS F 1 MG |
J3357 |
|
| USTEKINUMAB FOR SUBQ INJECTION 1 MG |
J3380 |
|
| INJECTION VEDOLIZUMAB 1 MG |
J3396 |
|
| INJECTION, VERTEPORFIN, 0.1 MG |
J7311 |
|
| INJECTION FA INTRAVITREAL IMPL 0.01 MG |
J7312 |
|
| DEXAMETHASONE INTRA IMPLANT |
J7313 |
|
| INJECTION FA INTRAVITREAL IMPL 0.01 MG |
J7314 |
|
| INJECTION FA INTRAVITREAL IMPL 0.01 MG |
J7318 |
|
| HYALURONAN/DERIVATIVE DUROLANE FOR IA INJ 1 MG |
J7320 |
|
| HYALURONAN/DERIVITIVE GENVISC 850 IA INJ 1 MG |
J7321 |
|
| HYAL HYALGN SUPARTZ/VSCO-3 IA INJ-D |
J7322 |
|
| HYALURONAN/DRIV HYMOVIS IA INJ 1 MG |
J7323 |
|
| EUFLEXXA INJ PER DOSE |
J7324 |
|
| ORTHOVISC INJ PER DOSE |
J7325 |
|
| SYNVISC OR SYNVISC-ONE |
J7326 |
|
| GEL-ONE |
J7327 |
|
| MONOVISC INJ PER DOSE |
J7328 |
|
| HYAL/DERIV GELSYN-3 IA INJ 0.1 MG |
J7329 |
|
| HYALURONAN/DERIVATIVE TRIVISC FOR IA INJ 1 MG |
J7331 |
|
| HYALURONAN/DERIVATIVE SYNOJOYNT IA INJ 1 MG |
J7332 |
|
| HYALURONAN/DERIVATIVE TRILURON IA INJ 1 MG |
J7333 |
|
| HYALURONAN/DERIVATIVE VISCO-3 IA INJ PER DOSE |
J7401 |
|
| MOMETASONE FUROATE SINUS IMPLANT 10 MCG |
J9022 |
|
| INJECTION ATEZOLIZUMAB 10 MG |
J9145 |
|
| INJECTION DARATUMUMAB 10 MG |
J9173 |
|
| INJECTION DURVALUMAB 10 MG |
J9176 |
|
| INJECTION ELOTUZUMAB 1MG |
J9308 |
|
| INJECTION RAMUCIRUMAB 5 MG |
J9311 |
|
| INJECTION RITUXIMAB 10 MG AND HYALURONIDASE |
J9312 |
|
| INJECTION RITUXIMAB 10 MG |
J9355 |
|
| INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR 10 MG |
J9356 |
|
| INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK |
J9358 |
|
| INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI 1 MG |
Q2041 |
|
| KTE-C19 TO 200 M A ANTI-CD19 CAR POS T CE P TD |
Q2042 |
|
| TISAGENLECLEUCEL TO 600 M CAR-POS VI T CE PER TD |
Q2043 |
|
| SIPLEUCEL-T AUTO CD54+ |
Q5101 |
|
| INJECTION, FILGRASTIM-SNDZ, BIOSIMILAR, (ZARXIO) |
Q5103 |
|
| INJECTION, INFLECTRA |
Q5104 |
|
| INJECTION, RENFLEXIS |
Q5107 |
|
| INJECTION BEVACIZUMAB-AWWB BIOSIMILAR 10 MG |
Q5108 |
|
| INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG |
Q5109 |
|
| INJECTION INFLIXIMAB-QBTX BIOSIMILAR 10 MG |
Q5110 |
|
| INJECTION, FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM), 1 MICROGRAM |
Q5111 |
|
| INJECTION, PEGFILGRASTIM-CBQV, BIOSIMILAR, (UDENYCA), 0.5 MG |
Q5112 |
|
| INJECTION TRASTUZUMAB-DTTB BIOSIMILAR 10 MG |
Q5113 |
|
| INJECTION TRASTUZUMAB-PKRB BIOSIMILAR 10 MG |
Q5114 |
|
| INJECTION TRASTUZUMAB-DKST BIOSIMILAR 10 MG |
Q5115 |
|
| INJECTION RITUXIMAB-ABBS BIOSIMILAR 10 MG |
Q5116 |
|
| INJECTION TRASTUZUMAB-QYYP BIOSIMILAR 10 MG |
Q5117 |
|
| INJECTION TRASTUZUMAB-ANNS BIOSIMILAR 10 MG |
Q5118 |
|
| INJECTION, BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG |
Q5119 |
|
| INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE 10 MG |
Q5120 |
|
| INJ PEGFILGRASTIM-BMEZ BIOSIMLR ZIEXTENZO 0.5 MG |
Q5121 |
|
| INJ INFLIXIMAB-AXXQ BIOSIMILAR AVSOLA 10 MG |
Q9991 |
|
| BUPRENORPH XR 100 MG OR LESS |
Q9992 |
|
| BUPRENORPHINE XR OVER 100 MG |
892 |
|
| SPECIAL PROCESSED DRUGS - FDA APPROVED GENE THERAPY |
A9513 |
|
| LUTETIUM LU 177 DOTATATE THERAPEUTIC 1 MCI |
C9035 |
|
| INJECTION ARIPIPRAZOLE LAUROXIL 1 MG |
C9036 |
|
| INJECTION PATISIRAN 0.1 MG |
C9037 |
|
| INJECTION RISPERIDONE 0.5 MG |
C9038 |
|
| INJECTION MOGAMULIZUMAB-KPKC 1 MG |
C9040 |
|
| INJECTION FREMANEZUMAB-VFRM 1 MG |
C9043 |
|
| INJECTION LEVOLEUCOVORIN 1 MG |
C9044 |
|
| INJECTION CEMIPLIMAB-RWLC 1 MG |
C9045 |
|
| INJECTION MOXETUMOMAB PASUDOTOX-TDFK 0.01 MG |
C9049 |
|
| INJECTION, TAGRAXOFUSP-ERZS, 10 MCG |
C9050 |
|
| INJECTION, EMAPALUMAB-LZSG, 1 MG |
C9051 |
|
| INJECTION, OMADACYCLINE, 1 MG |
C9052 |
|
| INJECTION, RAVULIZUMAB-CWVZ, 10 MG |
C9053 |
|
| INJECTION CRIZANLIZUMAB-TMCA 1 MG |
C9054 | Remove | 1/1/2021 | INJECTION LEFAMULIN XENLETA 1 MG |
C9055 |
|
| INJECTION BREXANOLONE 1 MG |
C9056 | Removed | 1/1/2021 | INJECTION GIVOSIRAN 0.5 MG |
C9057 | Removed | 1/1/2021 | INJECTION CETIRIZINE HCL 1 MG |
C9058 | Removed | 1/1/2021 | INJECTION PEGFILGRASTIM-BMEZ BIOSIMILAR 0.5 |
C9061 |
|
| INJECTION TEPROTUMUMAB-TRBW 10 MG |
C9063 |
|
| INJECTION EPTINEZUMAB-JJMR 1 MG |
C9122 |
|
| MOMETASONE FUROATE SINUS IMPLANT 10 MCG SINUVA |
C9130 | Removed | 1/1/2021 | INJ IMMUNE GLOBULIN BIVIGAM 500 MG |
C9133 |
|
| FACTOR IX RECOMBINANT |
C9134 |
|
| FACTOR XIII A-SUBUNIT RECOMB |
C9136 |
|
| FACTOR VIII (ELOCTATE) |
C9399 |
|
| UNCLASSIFIED DRUGS OR BIOLOGICALS |
C9399 |
|
| UNCLASSIFIED DRUGS OR BIOLOGICALS |
J0129 |
|
| ABATACEPT INJECTION |
J0135 |
|
| INJECTION, ADALIMUMAB, 20 MG |
J0178 |
|
| AFLIBERCEPT INJECTION |
J0179 |
|
| INJECTION BROLUCIZUMAB-DBLL 1 MG |
J0180 |
|
| INJECTION, AGALSIDASE BETA, 1 MG |
J0202 |
|
| INJECTION ALEMTUZUMAB 1 MG |
J0220 |
|
| ALGLUCOSIDASE ALFA INJECTION |
J0221 |
|
| LUMIZYME INJECTION |
J0222 |
|
| INJECTION PATISIRAN 0.1 MG |
J0223 |
|
| INJECTION GIVOSIRAN 0.5 MG |
J0256 |
|
| ALPHA 1 PROTEINASE INHIBITOR |
J0257 |
|
| GLASSIA INJECTION |
J0364 |
|
| INJECTION APOMORPHINE HYDROCHLORIDE 1 MG |
J0490 |
|
| BELIMUMAB INJECTION |
J0517 |
|
| INJECTION BENRALIZUMAB 1 MG |
J0567 |
|
| INJECTION CERLIPONASE ALFA 1 MG |
J0570 |
|
| BUPRENORPHINE IMPLANT 74.2MG |
J0584 |
|
| INJECTION BUROSUMAB-TWZA 1 MG |
J0585 |
|
| INJECTION,ONABOTULINUMTOXINA |
J0586 |
|
| ABOBOTULINUMTOXINA |
J0587 |
|
| INJ, RIMABOTULINUMTOXINB |
J0588 |
|
| INCOBOTULINUMTOXIN A |
J0591 |
|
| INJECTION DEOXYCHOLIC ACID 1 MG |
J0593 |
|
| INJECTION LANADELUMAB-FLYO 1 MG |
J0598 |
|
| C-1 ESTERASE, CINRYZE |
J0599 |
|
| INJECTION C-1 ESTERASE INHIBITOR 10 UNITS |
J0604 |
|
| CINACALCET ORAL 1 MG |
J0606 |
|
| INJECTION ETELCALCETIDE 0.1 MG |
J0630 |
|
| INJECTION, CALCITONIN SALMON, UP TO 400 UNITS |
J0638 |
|
| CANAKINUMAB INJECTION |
J0641 |
|
| INJECTION LEVOLEUCOVORIN 0.5 MG |
J0642 |
|
| INJECTION, LEVOLEUCOVORIN (KHAPZORY), 0.5 MG |
J0717 |
|
| CERTOLIZUMAB PEGOL INJ 1MG |
J0718 |
|
| CERTOLIZUMAB PEGOL INJ |
J0775 |
|
| COLLAGENASE, CLOST HIST INJ |
J0791 |
|
| INJECTION CRIZANLIZUMAB-TMCA 5 MG |
J0800 |
|
| INJECTION, CORTICOTROPIN, UP TO 40 UNITS |
J0881 |
|
| INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) |
J0885 |
|
| INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS |
J0888 |
|
| EPOETIN BETA NON ESRD |
J0894 |
|
| INJECTION DECITABINE 1 MG |
J0896 |
|
| INJECTION LUSPATERCEPT-AAMT 0.25 MG |
J0897 |
|
| DENOSUMAB INJECTION |
J1190 |
|
| INJECTION, DEXRAZOXANE HCL, PER 250 MG |
J1300 |
|
| ECULIZUMAB INJECTION |
J1301 |
|
| INJECTION EDARAVONE 1 MG |
J1303 |
|
| INJECTION RAVULIZUMAB-CWVZ 10 MG |
J1324 |
|
| INJECTION, ENFUVIRTIDE, 1 MG |
J1428 |
|
| INJECTION ETEPLIRSEN 10 MG |
J1429 |
|
| INJECTION GOLODIRSEN 10 MG |
J1438 |
|
| INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG AD |
J1439 |
|
| INJ FERRIC CARBOXYMALTOS 1MG |
J1442 |
|
| INJ FILGRASTIM EXCL BIOSIMIL |
J1443 |
|
| INJ FERRIC PRPP CIT SOL 0.1 MG IRON |
J1447 |
|
| INJECTION, TBO-FILGRASTIM, 1 MICROGRAM |
J1458 |
|
| INJECTION GALSULFASE 1 MG |
J1459 |
|
| INJ IVIG PRIVIGEN 500 MG |
J1555 |
|
| INJECTION IMMUNE GLOBULIN 100 MG |
J1556 |
|
| INJ, IMM GLOB BIVIGAM, 500MG |
J1557 |
|
| GAMMAPLEX INJECTION |
J1558 |
|
| INJECTION IMMUNE GLOBULIN XEMBIFY 100 MG |
J1559 |
|
| HIZENTRA INJECTION |
J1561 |
|
| GAMUNEX-C/GAMMAKED |
J1562 |
|
| INJECTION; IMMUNE GLOBULIN 10%, 5 GRAMS |
J1566 |
|
| INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P |
J1568 |
|
| OCTAGAM INJECTION |
J1569 |
|
| GAMMAGARD LIQUID INJECTION |
J1572 |
|
| FLEBOGAMMA INJECTION |
J1575 |
|
| INJ IG/HYALURONIDASE 100 MG IG |
J1599 |
|
| IVIG NON-LYOPHILIZED, NOS |
J1599 |
|
| IVIG NON-LYOPHILIZED, NOS |
J1602 |
|
| GOLIMUMAB FOR IV USE 1MG |
J1628 |
|
| INJECTION GUSELKUMAB 1 MG |
J1640 |
|
| INJECTION, HEMIN, 1 MG |
J1645 |
|
| INJECTION, DALTEPARIN SODIUM, PER 2500 IU |
J1675 |
|
| INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS |
J1743 |
|
| IDURSULFASE INJECTION |
J1744 |
|
| ICATIBANT INJECTION |
J1745 |
|
| INJ INFLIXIMAB EXCL BIOSIMILR 10 MG |
J1746 |
|
| INJECTION IBALIZUMAB-UIYK 10 MG |
J1786 |
|
| IMUGLUCERASE INJECTION |
J1817 |
|
| INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS |
J1930 |
|
| INJECTION, LANREOTIDE, 1 MG |
J1931 |
|
| INJECTION, LARONIDASE, 0.1 MG |
J2170 |
|
| Mecasermin injection |
J2182 |
|
| INJECTION MEPOLIZUMAB 1MG |
J2212 |
|
| METHYLNALTREXONE INJECTION |
J2315 |
|
| INJECTION NALTREXONE DEPOT FORM 1 MG |
J2323 |
|
| NATALIZUMAB INJECTION |
J2350 |
|
| INJECTION OCRELIZUMAB 1 MG |
J2353 |
|
| INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG |
J2355 |
|
| INJECTION, OPRELVEKIN, 5 MG |
J2357 |
|
| INJECTION, OMALIZUMAB, 5 MG |
J2440 |
|
| INJECTION, PAPAVERINE HCL, UP TO 60 MG |
J2503 |
|
| INJECTION, PEGAPTANIB SODIUM, 0.3 MG |
J2505 |
|
| INJECTION, PEGFILGRASTIM, 6 MG |
J2507 |
|
| PEGLOTICASE INJECTION |
J2562 |
|
| PLERIXAFOR INJECTION |
J2778 |
|
| RANIBIZUMAB INJECTION |
J2783 |
|
| INJECTION, RASBURICASE, 0.5 MG |
J2786 |
|
| INJECTION RESLIZUMAB 1MG |
J2793 |
|
| RILONACEPT INJECTION |
J2796 |
|
| ROMIPLOSTIM INJECTION |
J2797 |
|
| INJECTION ROLAPITANT 0.5 MG |
J2820 |
|
| INJECTION, SARGRAMOSTIM (CM-CSF), 50 MCG |
J2840 |
|
| INJ SEBELIPASE ALFA 1 MG |
J2940 |
|
| INJECTION, SOMATREM, 1 MG |
J2941 |
|
| INJECTION, SOMATROPIN, 1 MG |
J3095 |
|
| TELEVANCIN INJECTION |
J3110 |
|
| INJECTION, TERIPARATIDE, 10 MCG |
J3111 | Added | 1/1/2021 | INJECTION ROMOSOZUMAB-AQQG 1 MG |
J3140 |
|
| INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG |
J3240 |
|
| INJECTION, THYROTROPIN, UP TO 10 I.U. |
J3245 |
|
| INJECTION TILDRAKIZUMAB 1 MG |
J3262 |
|
| TOCILIZUMAB INJECTION |
J3285 |
|
| INJECTION, TREPROSTINIL, 1 MG |
J3304 |
|
| INJECT TRIAMCINOLONE ACETONIDE PF ER MS F 1 MG |
J3316 |
|
| INJECTION TRIPTORELIN EXTENDED-RELEASE 3.75 MG |
J3357 |
|
| USTEKINUMAB FOR SUBQ INJECTION 1 MG |
J3380 |
|
| INJECTION VEDOLIZUMAB 1 MG |
J3385 |
|
| VELAGLUCERASE ALFA |
J3396 |
|
| INJECTION, VERTEPORFIN, 0.1 MG |
J3397 |
|
| INJECT TRIAMCINOLONE ACETONIDE PF ER MS F 1 MG |
J3398 |
|
| INJECTION VORETIGENE NEPARVOVEC-RZYL 1 B VEC G |
J3399 |
|
| INJ AVSX-101-XIOI P-TX TO 5X10^15 VCTR GNOMS |
J3490 |
|
| UNCLASSIFIED DRUGS |
J3590 |
|
| UNCLASSIFIED BIOLOGICS |
J3591 |
|
| UNCLASS RX/BIOLOGICAL USED FOR ESRD ON DIALYSIS |
J7169 |
|
| INJ COAGULATION FACTOR XA INACTIVATED-ZHZO 10 MG |
J7170 |
|
| INJECTION EMICIZUMAB-KXWH 0.5 MG |
J7175 |
|
| INJ FACTOR X (HUMAN) 1IU |
J7177 |
|
| INJECTION HUMAN FIBRINOGEN CONCENTRATE 1 MG |
J7179 |
|
| VONVENDI INJ 1 IU VWF:RCO |
J7180 |
|
| FACTOR XIII ANTI-HEM FACTOR |
J7181 |
|
| FACTOR XIII RECOMB A-SUBUNIT |
J7182 |
|
| FACTOR VIII RECOMB NOVOEIGHT |
J7183 |
|
| WILATE INJECTION |
J7185 |
|
| XYNTHA INJ |
J7186 |
|
| ANTIHEMOPHILIC VIII/VWF COMP |
J7187 |
|
| INJECTION VON WILLEBRAND FACTOR COMPLEX HUMAN RISTOCETIN COFACTOR PER IV |
J7188 |
|
| INJECTION FACTOR VIII PER I.U. |
J7189 |
|
| FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICR |
J7190 |
|
| FACTOR VIII, (ANTI-HEMOPHILIC FACTOR (HUMAN)), PER I.U. |
J7191 |
|
| FACTOR VIII (PORCINE) |
J7192 |
|
| FACTOR VIII RECOMBINANT NOS |
J7193 |
|
| FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U. |
J7194 |
|
| FACTOR IX, COMPLEX, PER I.U. |
J7195 |
|
| FACTOR IX RECOMBINANT NOS |
J7196 |
|
| ANTITHROMBIN RECOMBINANT |
J7197 |
|
| ANTITHROMBIN III (HUMAN), PER I.U. |
J7198 |
|
| ANTI-INHIBITOR, PER I.U. |
J7199 |
|
| HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED |
J7200 |
|
| FACTOR IX RECOMBINAN RIXUBIS |
J7201 |
|
| INJ FACTOR IX FC FUS PROTEIN PER IU |
J7202 |
|
| FACTOR IX IDELVION INJ |
J7203 |
|
| INJECTION FACTOR IX GLYCOPEGYLATED 1 IU |
J7204 |
|
| INJ FAC VIII ANTIHEM FAC GLYCOPEGYLATD-EXEI P-IU |
J7207 |
|
| FACTOR VIII PEGYLATED RECOMB |
J7208 |
|
| INJECTION FACTOR VIII PEGYLATED-AUCL 1 IU |
J7209 |
|
| FACTOR VIII NUWIQ RECOMB 1IU |
J7311 |
|
| INJECTION FA INTRAVITREAL IMPL 0.01 MG |
J7312 |
|
| DEXAMETHASONE INTRA IMPLANT |
J7313 |
|
| INJECTION FA INTRAVITREAL IMPL 0.01 MG |
J7314 |
|
| INJECTION FA INTRAVITREAL IMPL 0.01 MG |
J7318 |
|
| HYALURONAN/DERIVATIVE DUROLANE FOR IA INJ 1 MG |
J7320 |
|
| HYALURONAN/DERIVITIVE GENVISC 850 IA INJ 1 MG |
J7321 |
|
| HYAL HYALGN SUPARTZ/VSCO-3 IA INJ-D |
J7322 |
|
| HYALURONAN/DRIV HYMOVIS IA INJ 1 MG |
J7323 |
|
| EUFLEXXA INJ PER DOSE |
J7324 |
|
| ORTHOVISC INJ PER DOSE |
J7325 |
|
| SYNVISC OR SYNVISC-ONE |
J7326 |
|
| GEL-ONE |
J7327 |
|
| MONOVISC INJ PER DOSE |
J7328 |
|
| HYAL/DERIV GELSYN-3 IA INJ 0.1 MG |
J7329 |
|
| HYALURONAN/DERIVATIVE TRIVISC FOR IA INJ 1 MG |
J7331 |
|
| HYALURONAN/DERIVATIVE SYNOJOYNT IA INJ 1 MG |
J7332 |
|
| HYALURONAN/DERIVATIVE TRILURON IA INJ 1 MG |
J7333 |
|
| HYALURONAN/DERIVATIVE VISCO-3 IA INJ PER DOSE |
J7401 |
|
| MOMETASONE FUROATE SINUS IMPLANT 10 MCG |
J7518 |
|
| MYCOPHENOLIC ACID, ORAL, 180 MG |
J7527 |
|
| ORAL EVEROLIMUS |
J7677 |
|
| REVEFENACIN INHAL SOL NONCOMPND ADM DME 1 MCG |
J7686 |
|
| TREPROSTINIL, NON-COMP UNIT |
J8499 | Removed | 1/1/2021 | NOS DRUG, ORAL |
J8565 |
|
| GEFITINIB, ORAL, 250 MG |
J8650 |
|
| Nabilone oral |
J8705 |
|
| TOPOTECAN ORAL |
J8999 |
|
| NOS PRES DRUG, ORAL, CHEMO |
J9015 |
|
| ALDESLEUKIN/SINGLE USE VIAL |
J9017 |
|
| ARSENIC TRIOXIDE, 1MG |
J9019 |
|
| ERWINAZE INJECTION |
J9022 |
|
| INJECTION ATEZOLIZUMAB 10 MG |
J9023 |
|
| INJECTION AVELUMAB 10 MG |
J9027 |
|
| INJECTION, CLOFARABINE, 1 MG |
J9034 |
|
| INJ. BENDEKA 1 MG |
J9036 |
|
| INJECTION BENDAMUSTINE HYDROCHLORIDE 1 MG |
J9039 |
|
| INJECTION BLINATUMOMAB 1 MICROGRAM |
J9041 |
|
| INJECTION BORTEZOMIB 0.1 MG |
J9042 |
|
| BRENTUXIMAB VEDOTIN INJ |
J9043 |
|
| CABAZITAXEL INJECTION |
J9044 |
|
| INJECTION BORTEZOMIB NOS 0.1 MG |
J9047 |
|
| INJECTION, CARFILZOMIB, 1 MG |
J9050 |
|
| CARMUSTINE INJECTION |
J9055 |
|
| INJECTION, CETUXIMAB, 10 MG |
J9057 |
|
| INJECTION COPANLISIB 1 MG |
J9118 | Added | 1/1/2021 | INJECTION CALASPARGASE PEGOL-MKNL 10 UNITS |
J9145 |
|
| INJECTION DARATUMUMAB 10 MG |
J9153 |
|
| INJECTION LIPOSOMAL 1 MG DNR AND 2.27 MG CA |
J9173 |
|
| INJECTION DURVALUMAB 10 MG |
J9176 |
|
| INJECTION ELOTUZUMAB 1MG |
J9177 |
|
| INJECTION ENFORTUMAB VEDOTIN-EJFV 0.25 MG |
J9198 |
|
| INJ GEMCITABINE HYDROCHLORIDE INFUGEM 100 MG |
J9199 |
|
| INJECTION GEMCITABINE HCL INFUGEM 200 MG |
J9203 |
|
| INJ GEMTUZUMAB OZOGAMICIN 0.1 MG |
J9205 |
|
| INJ IRINOTECAN LIPOSOME 1 MG |
J9212 |
|
| INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG |
J9213 |
|
| INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS |
J9215 |
|
| INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU |
J9216 |
|
| INTERFERON, GAMMA 1-B, 3 MILLION UNITS |
J9225 |
|
| HISTRELIN IMPLANT, 50 MG |
J9226 |
|
| SUPPRELIN LA IMPLANT |
J9228 |
|
| IPILIMUMAB INJECTION |
J9229 |
|
| INJECTION INOTUZUMAB OZOGAMICIN 0.1 MG |
J9246 |
|
| INJECTION MELPHALAN EVOMELA 1 MG |
J9261 |
|
| INJECTION NELARABINE 50 MG |
J9262 |
|
| INJ, OMACETAXINE MEP, 0.01MG |
J9264 |
|
| INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG |
J9266 |
|
| PEGASPARGASE/SINGL DOSE VIAL |
J9271 |
|
| INJECTION PEMBROLIZUMAB 1 MG |
J9285 |
|
| INJECTION OLARATUMAB 10 MG |
J9299 |
|
| INJECTION NIVOLUMAB 1 MG |
J9301 |
|
| OBINUTUZUMAB INJ |
J9303 |
|
| PANITUMUMAB INJECTION |
J9305 |
|
| INJECTION, PEMETREXED, 10 MG |
J9306 |
|
| INJECTION, PERTUZUMAB, 1 MG |
J9308 |
|
| INJECTION RAMUCIRUMAB 5 MG |
J9309 |
|
| INJECTION POLATUZUMAB VEDOTIN-PIIQ 1 MG |
J9311 |
|
| INJECTION RITUXIMAB 10 MG AND HYALURONIDASE |
J9312 |
|
| INJECTION RITUXIMAB 10 MG |
J9325 |
|
| INJ TALIMOGENE LAHERPAREPVEC |
J9352 |
|
| INJECTION TRABECTEDIN 0.1MG |
J9354 |
|
| INJ, ADO-TRASTUZUMAB EMT 1MG |
J9355 |
|
| INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR 10 MG |
J9356 |
|
| INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK |
J9358 |
|
| INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI 1 MG |
J9395 |
|
| INJECTION, FULVESTRANT, 25 MG |
J9400 |
|
| INJ, ZIV-AFLIBERCEPT, 1MG |
J9999 |
|
| NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS |
J9999 |
|
| NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS |
Q0138 |
|
| FERUMOXYTOL, NON-ESRD |
Q0515 |
|
| INJECTION, SERMORELIN ACETATE, 1 MICROGRAM |
Q2026 |
|
| RADIESSE INJECTION |
Q2027 |
|
| SCULPTRA INJECTION |
Q2028 |
|
| INJ, SCULPTRA, 0.5MG |
Q2041 |
|
| KTE-C19 TO 200 M A ANTI-CD19 CAR POS T CE P TD |
Q2042 |
|
| TISAGENLECLEUCEL TO 600 M CAR-POS VI T CE PER TD |
Q2043 |
|
| SIPLEUCEL-T AUTO CD54+ |
Q2050 |
|
| DOXORUBICIN INJ 10MG |
Q3025 |
|
| INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE |
Q3026 |
|
| INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE |
Q3027 |
|
| INJ BETA INTERFERON IM 1 MCG |
Q4074 |
|
| ILOPROST NON-COMP UNIT DOSE |
Q5101 |
|
| INJECTION, FILGRASTIM-SNDZ, BIOSIMILAR, (ZARXIO) |
Q5103 |
|
| INJECTION, INFLECTRA |
Q5104 |
|
| INJECTION, RENFLEXIS |
Q5106 |
|
| INJ EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS |
Q5107 |
|
| INJECTION BEVACIZUMAB-AWWB BIOSIMILAR 10 MG |
Q5108 |
|
| INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG |
Q5109 |
|
| INJECTION INFLIXIMAB-QBTX BIOSIMILAR 10 MG |
Q5110 |
|
| INJECTION, FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM), 1 MICROGRAM |
Q5111 |
|
| INJECTION, PEGFILGRASTIM-CBQV, BIOSIMILAR, (UDENYCA), 0.5 MG |
Q5112 |
|
| INJECTION TRASTUZUMAB-DTTB BIOSIMILAR 10 MG |
Q5113 |
|
| INJECTION TRASTUZUMAB-PKRB BIOSIMILAR 10 MG |
Q5114 |
|
| INJECTION TRASTUZUMAB-DKST BIOSIMILAR 10 MG |
Q5115 |
|
| INJECTION RITUXIMAB-ABBS BIOSIMILAR 10 MG |
Q5116 |
|
| INJECTION TRASTUZUMAB-QYYP BIOSIMILAR 10 MG |
Q5117 |
|
| INJECTION TRASTUZUMAB-ANNS BIOSIMILAR 10 MG |
Q5118 |
|
| INJECTION, BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG |
Q5119 |
|
| INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE 10 MG |
Q5120 |
|
| INJ PEGFILGRASTIM-BMEZ BIOSIMLR ZIEXTENZO 0.5 MG |
Q5121 |
|
| INJ INFLIXIMAB-AXXQ BIOSIMILAR AVSOLA 10 MG |
Q9991 |
|
| BUPRENORPH XR 100 MG OR LESS |
Q9992 |
|
| BUPRENORPHINE XR OVER 100 MG |
S0145 |
|
| INJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER ML |
J9119 |
|
| CEMIPLIMAB-RWLC |
J9204 |
|
| MOGAMULIZUMAB - KPKC |
J9269 |
|
| TAGRAXOFUSP-ERZS |
J9313 |
|
| MOXETUMOMAB PASUDOTOX-TDFK |
J9179 |
|
| ERIBULIN MESYLATE INJECTION |