DRUGS BILLED UNDER MISCELLANEOUS CODES J3490, J3590, J9999 OR C9399 COVERAGE INFORMATION
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1 ACTEMRA (toclizumab) 10/21/13 ADASUVE (loxapine aerosol powder breath activated) 01/24/14 ADDAMEL N INJ (Trace Min (CR-CU-F-FE-I-MN-MO-SE-ZN) INJ) 05/20/13 ADYNOVATE (Antihemophilic Factor Recomb Pegylated for Inj.) 12/01/15 PA PA PA-Use C9137 FDA LABELING ALPROLIX (Coagulation Facor IX (Recom) (RFIXFC) for Inj. 04/18/14 ARTICADENT (articaine-epinephrine) 09/25/14 ARISTADA (aripiprazole lauroxil) 10/06/15 PA PA PA-Use C9470 FDA LABELING ASCLERA INJ (polidocanol (laureth-9)) 08/27/13 NC NC NC Non-Covered Cosmetic Product AVEED (testosterone undecanoate) 03/10/14 BENDEKA (Bendamustine HCL IV Soln) 12/11/15 BETAMETHASONE (betamethasone sodium phosphate) 01/01/15 BOSULIF (bosutinib) 10/08/13 PA NC PA 1. Diagnosis of chronic, accelerated, or blast phase Philadelphia chromosome-positive chronic myelogenous leukemia (CML) with resistance or intolerance to prior therapy; and 2. Must have t/f first line tyrosine kinase inhibitor.
2 BREVITAL SOD INJ (methohexital sodium) 03/20/13 BRIVIACT INJ (Brivaracetam IV Soln.) 05/13/16 BRIDION (Sugammadex Sodium IV) 01/08/16 BROMPHENIRAM INJ (brompheniramine maleate) 01/01/15 BUPIVILOG (triamcinolone & bupivacaine hcl) 02/18/14 CINQAIR (Reslizumab IV Infusion Soln) 04/01/16 CLIN SINGLE KIT USE (clindamycin phosphate) 08/24/15 COAGDEX (Coagulation Factor X (Human) for Inj. 12/01/15 COSENTYX (secukinumab subcutaneous soln auto-injector) 01/30/15 DARZALEX (daratumumab IV Soln) 11/17/15 DEFITELIO (Defibrotide Sodium IV Soln.) 04/04/16 DEX COMBO (dexamethasone acetate & sodium phosphate Inj) EMPLICITI (elotuzumab for IV Soln.) 01/01/15 11/30/15
3 ENVARSUS XR (tacrolimus tab SR 24HR) EPHEDRINE (ephedrine sulfate sodium chloride injection) EPINEPHRINE (epinephrine hcl PF IV Solution) EVOMELA (Melphalan HCL for Inj.) 09/24/15 07/01/15 11/14/14 04/06/16 PA PA PA-J7503 FDA LABELING GATTEX (teduglutide (RDNA) for inj kit) 01/29/13 PA NC NC FDA LABELING GAZYVA (obinutuzumab soln for IV infusion 1000 mg/40ml (25 mg/ml)) 11/08/13 PA PA PA -- use J9301 FDA LABELING GLYCOPHOS (sodium glycerophosphate IV Soln) 05/20/13 HYQVIA (IMMUN GLOB INJ) 09/18/14 IDELVION (Coagulation Factor IX (RECOMB) (RIX-FP) For Inj. 03/04/16 IMLYGIC (talimogene laherparepvec Intralesional Inj.) 11/02/15 PA PA PA-Use C9172 FDA LABELING INJECTAFER INJ (750/15ML (ferric carboxymaltose IV soln) 07/25/13 INVEGA TRINZA (paliperidone palmitate IM Extend-Release Susp) 06/03/15 IXINITY (Coagulation Factor IX (Recombinant) for Inj.) 05/29/15
4 K-10 LIDO KIT (triamcinolone inj 10 mg/ml & lidocaine hcl inj 2% kit) 06/16/15 KABIVEN (*amino ac 3.3%-dextrose 9.8%-lipid 3.9%-electrolyte iv emul) 09/25/14 KANUMA (sebelipase alfa IV SOLN) 12/08/15 KCENTRA INJ (prothrombin complex conc human for inj kit 500 unit) 05/23/13 KENGREAL (cangrelor tetrasodium for IV soln.) 07/01/15 PA PA PA-Use C9460 FDA LABELING KETOROCAINE (ketorolac trometh inj) 09/08/14 KYNAMRO INJ (mipomersen sodium inj) 03/01/13 PA NC NC FDA LABELING LIDOLOG (triamcinololne & lidocaine Hcl) 02/11/14 LUPANETA (leoprolide and norethindrone) 01/16/14 MARBETA-L (betameth na pho&ace inj) 09/08/14 MARLIDO (lidocaine hcl & bupivacaine hcl) 02/11/14 MEROPENEM (meropenem & sodium chloride 0.9% for IV Soln) 09/15/15 METHYLP/LIDO (methylprednisolone w/lidocaine Inj.) 01/01/15
5 METHYLPREDNISOLONE (methylprednisolone acetate inj) 01/01/15 MIC COMBO INJ (methionine-inos-chol-adenosine-levocarnitine- B-12 IM Inj.) 01/01/15 MLK PROCEDUR KIT F1 (triamcinolone inj 40mg/ml & bupiv 0.5% & Lido 2% kit) 01/24/14 MIRCERA (methoxy peg-epoetin beta ) 10/01/14 MOXIFLOXACIN (moxifloxacin HCL IV Soln) 07/30/15 MULTI - (methylprednisolone & lidocaine) 02/18/14 MYLEPT (metreleptin Inj 11.3mg) 04/11/14 NATPARA (parathyroid hormone(recombinant) for Inj. 04/02/15 NOVOEIGHT (antihemophilic factor (recombinant) 03/12/15 NUCALA (mepolizumab for Inj.) 11/12/15 PA PA PA-Use C9473 FDA LABELING OMIDRIA (phenylephrine-ketorolac Intraocluar Soln) 04/02/15 PA PA PA-Use C9447 FDA LABELING ONIVYDE (Irinotecan HCL Liposome IV Inj.) 10/26/15 PA PA PA-Use C9474 FDA LABELING OTREXUP (methotrexate soln pf auto-injector) 12/13/13
6 OXYTOCIN/LAC (Oxytocin-Lactated Ringers IV Soln 30 unit/500ml) 07/01/15 PEDITRACE (*TRACE MIN (CU-F-I-MN-SE-ZN) Inj) 05/20/13 PORTRAZZA (necitumumab IV SOLN) 12/11/15 PA PA PA-Use C9475 FDA LABELING PRAXBIND (idarucizumab IV Soln) 10/19/15 SIVEXTRO (phosphate for IV Solution) 06/20/14 STRENSIQ (asfotase alfa subcutaneous Inj.) 10/23/15 SYNERA (Lidocaine-Tetracaine Topical Patch) 03/06/14 TALTZ (Ixekizumab subcutaneous Soln., Auto-Inj.) 03/23/16 TANZEUM INJ PEN-INJECTOR (albiglutide) 06/05/14 TEST EO-PRO-Inj CYP 220 (testosterone cypionate & Prop Im Inj. Oil MG/ML) 01/01/15 TESTOSTERONE (testosterone implant pellets) 01/01/15 TESTOSTERONE (testosterone cypionate IM Inj.) 01/01/15 TRIAMCINOLONE + LIDOCAINE (triamcinolone acetonidelidocaine Inj.) 01/01/15
7 TRIAMCINOLONE (triamcinolone diacetate inj.) 01/01/15 UNITUXIN INJ. (dinutuximab iv soln) 07/06/15 VANCOMYCIN HCL (Vancomycin HCL In Sodium Chloride Soln) 04/18/16 VARITHENA (polidocanol (laureth-9) Inj foam) 04/10/14 VASOSTRICT (vasopressin IV Solution) 11/12/14 VAZCULEP (phenylephrine HCL IV Solution 10MG/ML) 09/26/14 VIZAMYL (flutemetamol F 18 IV Soln) 08/10/15 VORAXAZE (glucarpidase for IV inj 1000 unit) 04/09/13 NC NC NC Not covered in a retail pharmacy, physician's office setting or outpatient hospital. XOFIGO (radium RA 223 dichloride injection) 05/15/13 ZINC GLUCONA (zinc gluconate) 03/07/14 Zomaction Inj. (somatropin for Inj.) 05/18/15
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