HCPCS REQUIRING CORRESPONDING NDC CODES

Transcription

1 HCPCS REQUIRING CORRESPONDING NDC CODES A list of the HCPCS which will require a corresponding NDC can be found on the FHSC Website at If you are unable to access the FHSC Website, please contact FHSC s Provider Inquiry Unit at (907) or (800) (toll-free in Alaska) to request a hard copy. The list of procedure codes affected by the J Code NDC Requirements is now available on the FHSC Website listed above! Please use this list when determining which codes require a NDC code in order to be considered for reimbursement. The Deficit Reduction Act requires State Medicaid programs to collect rebates for physician and outpatient facility administered drugs. To facilitate this mandate, beginning April 1, 2008, drugs administered in a clinical setting which are billed with a HCPCS code or a revenue code 025x or 063x must include the corresponding NDC number, unit of measurement, and numeric quantity. Beginning April 1, 2008, payment for physician administered drugs will be based on the NDC and NDC quantity not on the HCPCS codes and units. Providers may bill for administration of the drug using the appropriate CPT code. For rebateable drugs, Medicaid will pay for the drug only if the manufacturer is participating in the Federal Drug Rebate Program. The CMS website provides a complete list of rebateable drugs. Claims submitted for drugs from manufacturers that are not part of the drug rebate program on the claim date of services will be denied.

2

3 Proc Code Description J0120 INJ TETRACYCLINE UP TO 250 MG J0128 INJ ABARELIX 10 MG J0129 INJ ABATACEPT 10 MG J0130 INJ ABCIXIMAB 10 MG J0132 INJ ACETYLCYSTEINE 100 MG J0133 INJ ACYCLOVIR 5 MG J0135 INJ ADALIMUMAB 20 MG J0150 INJ ADENOSINE FOR THERAPEUTIC USE 6 MG J0170 INJ ADRENALIN EPINEPHRINE UP TO 1 ML AMPULE J0180 INJ AGALSIDASE BETA 1 MG J0200 INJ ALATROFLOXACIN MESYLATE 100 MG J0205 INJ ALGLUCERASE PER 10 UNITS J0207 INJ AMIFOSTINE 500 MG J0210 INJ METHYLDOPATE HCL UP TO 250 MG J0215 INJ ALEFACEPT 0.5 MG J0220 INJ AGLUCOSIDASE ALFA 10 MG J0256 INJ ALPHA 1 - PROTEINASE INHIBITOR - HUMAN 10 MG J0278 INJ AMIKACIN SULFATE 100 MG J0280 INJ, AMINOPHYLLIN, UP TO 250 MG J0282 INJ AMIODARONE HCL 30 MG J0285 INJ AMPHOTERICIN B 50 MG J0287 INJ AMPHOTERICIN B LIPID COMPLEX 10 MG J0288 INJ AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX 10 MG J0289 INJ AMPHOTERICIN B LIPOSOME 10 MG J0290 INJ AMPICILLIN SODIUM 500 MG J0295 INJ AMPICILLIN SODIUM/SULBACTAM SODIUM PER 1.5 GM J0300 INJ AMOBARBITAL UP TO 125 MG J0330 INJ SUCCINYLCHOLINE CHLORIDE UP TO 20 MG J0348 INJ ANADULAFUNGIN 1 MG J0350 INJ ANISTREPLASE PER 30 UNITS J0360 INJ HYDRALAZINE HCL UP TO 20 MG J0364 INJ APOMORPHINE HCL 1 MG J0365 INJ APROTONIN KIU J0380 INJ METARAMINOL BITARTRATE PER 10 MG J0390 INJ CHLOROQUINE HCL UP TO 250 MG J0395 INJ ARBUTAMINE HCL 1 MG J0400 INJ ARIPIPRAZOLE IM 0.25 MG J0456 INJ AZITHROMYCIN 500 MG J0460 INJ ATROPINE SULFATE UP TO 0.3 MG J0470 INJ DIMERCAPROL PER 100 MG J0475 INJ BACLOFEN 10 MG J0476 INJ BACLOFEN 50 MCG FOR INTRATHECAL TRIAL J0480 INJ BASILIXIMAB 20 MG J0500 INJ DICYCLOMINE HCL UP TO 20 MG J0515 INJ BENZTROPINE MESYLATE PER 1 MG J0520 INJ BETHANECHOL CHLORIDE MYOTONACHOL OR URECHOLINE UP TO 5 MG J0530 INJ PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE UP TO 600 J0540 INJ PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE UP TO 1 20 J0550 INJ PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE UP TO 2 40 J0560 INJ PENICILLIN G BENZATHINE UP TO UNITS J0570 INJ PENICILLIN G BENZATHINE UP TO UNITS Page 1 of 12 February 8, 2008

4 J0580 J0583 J0585 J0587 J0592 J0594 J0595 J0600 J0610 J0620 J0630 J0636 J0637 J0640 J0670 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0706 J0710 J0713 J0715 J0720 J0725 J0735 J0740 J0743 J0744 J0745 J0760 J0770 J0780 J0795 J0800 J0835 J0850 J0878 J0881 J0882 J0885 J0886 J0894 J0895 J0900 J0945 J0970 J1000 INJ PENICILLIN G BENZATHINE UP TO UNITS INJ BIVALIRUDIN 1 MG BOTULINUM TOXIN TYPE A PER UNIT BOTULINUM TOXIN TYPE B PER 100 UNITS INJ BUPRENORPHINE HCL 0.1 MG INJ BUSULFAN 1 MG INJ BUTORPHANOL TARTRATE 1 MG INJ EDETATE CALCIUM DISODIUM UP TO 1000 MG INJ CALCIUM GLUCONATE PER 10 ML INJ CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE PER 10 ML INJ CALCITONIN SALMON UP TO 400 UNITS INJ CALCITRIOL 0.1 MCG INJ CASPOFUNGIN ACETATE 5 MG INJ LEUCOVORIN CALCIUM PER 50 MG INJ MEPIVACAINE HCL PER 10 ML INJ CEFAZOLIN SODIUM 500 MG INJ CEFEPIME HCL 500 MG INJ CEFOXITIN SODIUM 1 GM INJ CEFTRIAXONE SODIUM PER 250 MG INJ STERILE CEFUROXIME SODIUM PER 750 MG INJ CEFOTAXIME SODIUM PER GM INJ BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIUM PHOSPHATE INJ BETAMETHASONE SODIUM PHOSPHATE PER 4 MG INJ CAFFEINE CITRATE 5MG INJ CEPHAPIRIN SODIUM UP TO 1 GM INJ CEFTAZIDIME PER 500 MG INJ CEFTIZOXIME SODIUM PER 500 MG INJ CHLORAMPHENICOL SODIUM SUCCINATE UP TO 1 GM INJ CHORIONIC GONADOTROPIN PER USP UNITS INJ CLONIDINE HCL 1 MG INJ CIDOFOVIR 375 MG INJ CILASTATIN SODIUM; IMIPENEM PER 250 MG INJ CIPROFLOXACIN FOR IV INFUSION 200 MG INJ CODEINE PHOSPHATE PER 30 MG INJ COLCHICINE PER 1MG INJ COLISTIMETHATE SODIUM UP TO 150 MG INJ PROCHLORPERAZINE UP TO 10 MG INJ CORTICORELIN OVINE TRIFLUTATE 1 MICROGRAM INJ CORTICOTROPIN UP TO 40 UNITS INJ COSYNTROPIN PER 0.25 MG INJ CYTOMEGALOVIRUS IMMUNE GLOBULIN IV (HUMAN) PER VIAL INJ DAPTOMYCIN 1 MG INJ DARBEPOETIN ALFA 1 MICROGRAM (NON-ESRD USE) INJ DARBEPOETIN ALFA 1 MICROGRAM (FOR ESRD ON DIALYSIS) INJ EPOETIN ALFA (FOR NON-ESRD USE) 1000 UNITS INJ EPOETIN ALFA 1000 UNITS (FOR ESRD ON DIALYSIS) INJ DECITABINE 1 MG INJ DEFEROXAMINE MESYLATE 500 MG INJ TESTOSTERONE ENANTHATE AND ESTRADIOL VALERATE UP TO 1 CC INJ BROMPHENIRAMINE MALEATE PER 10 MG INJ ESTRADIOL VALERATE UP TO 40 MG INJ DEPO-ESTRADIOL CYPIONATE UP TO 5 MG Page 2 of 12 February 8, 2008

5 J1020 J1030 J1040 J1051 J1055 J1056 J1060 J1070 J1080 J1094 J1100 J1110 J1120 J1160 J1162 J1165 J1170 J1180 J1190 J1200 J1205 J1230 J1240 J1245 J1260 J1265 J1270 J1300 J1320 J1324 J1325 J1327 J1330 J1335 J1364 J1380 J1390 J1410 J1430 J1435 J1436 J1438 J1440 J1441 J1450 J1451 J1452 J1455 J1457 J1458 J1460 J1470 INJ METHYLPREDNISOLONE ACETATE 20 MG INJ METHYLPREDNISOLONE ACETATE 40 MG INJ METHYLPREDNISOLONE ACETATE 80 MG INJ MEDROXYPROGESTERONE ACETATE 50 MG INJ MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 150 MG INJ MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE 5MG / 25MG INJ TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE UP TO 1 ML INJ TESTOSTERONE CYPIONATE UP TO 100 MG INJ TESTOSTERONE CYPIONATE 1 CC 200 MG INJ DEXAMETHASONE ACETATE 1 MG INJ DEXAMETHASONE SODIUM PHOSPHATE 1MG INJ DIHYDROERGOTAMINE MESYLATE PER 1 MG INJ ACETAZOLAMIDE SODIUM UP TO 500 MG INJ DIGOXIN UP TO 0.5 MG INJ DIGOXIN IMMUNE FAB (OVINE) PER VIAL INJ PHENYTOIN SODIUM PER 50 MG INJ HYDROMORPHONE UP TO 4 MG INJ DYPHYLLINE UP TO 500 MG INJ DEXRAZOXANE HCL PER 250 MG INJ DIPHENHYDRAMINE HCL UP TO 50 MG INJ CHLOROTHIAZIDE SODIUM PER 500 MG INJ METHADONE HCL UP TO 10 MG INJ DIMENHYDRINATE UP TO 50 MG INJ DIPYRIDAMOLE PER 10 MG INJ DOLASETRON MESYLATE 10 MG INJ DOPAMINE HCL 40 MG INJ DOXERCALCIFEROL 1 MCG INJ ECULIZUMAB 10 MG INJ AMITRIPTYLINE HCL UP TO 20 MG INJ ENFUVIRTIDE 1 MG INJ EPOPROSTENOL 0.5 MG INJ EPTIFIBATIDE 5 MG INJ ERGONOVINE MALEATE UP TO 0.2 MG INJ ERTAPENEM SODIUM 500 MG INJ ERYTHROMYCIN LACTOBIONATE PER 500 MG INJ ESTRADIOL VALERATE UP TO 10 MG INJ ESTRADIOL VALERATE UP TO 20 MG INJ ESTROGEN CONJUGATED PER 25 MG INJ ETHANOLAMINE OLEATE 100 MG INJ ESTRONE PER 1 MG INJ ETIDRONATE DISODIUM PER 300 MG INJ ETANERCEPT 25 MG INJ FILGRASTIM (G-CSF) 300 MCG INJ FILGRASTIM (G-CSF) 480 MCG INJ FLUCONAZOLE 200 MG INJ FOMEPIZOLE 15 MG INJ FOMIVIRSEN SODIUM INTRAOCULAR 1.65 MG INJ FOSCARNET SODIUM PER 1000 MG INJ GALLIUM NITRATE 1 MG INJ GALSULFASE 1 MG INJ GAMMA GLOBULIN IM 1 CC INJ GAMMA GLOBULIN IM 2 CC Page 3 of 12 February 8, 2008

6 J1480 INJ GAMMA GLOBULIN IM 3 CC J1490 INJ GAMMA GLOBULIN IM 4 CC J1500 INJ GAMMA GLOBULIN IM 5 CC J1510 INJ GAMMA GLOBULIN IM 6 CC J1520 INJ GAMMA GLOBULIN IM 7 CC J1530 INJ GAMMA GLOBULIN IM 8 CC J1540 INJ GAMMA GLOBULIN IM 9 CC J1550 INJ GAMMA GLOBULIN IM 10 CC J1560 INJ GAMMA GLOBULIN IM OVER 10 CC J1561 INJ, IMMUNE GLOBULIN,(GAMUNEX) IV J1562 INJ IMMUNE GLOBULIN (VIVAGLOBIN) 100 MG J1565 INJ RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN IV 50 J1566 INJ IMMUNE GLOBULIN IV LYOPHILIZED (E.G. POWDER) NOT J1568 INJ IMMUNE GLOBULIN (OCTAGAM) IV NON-LYOPHILIZED (E.G J1569 INJ IMMUNE GLOBULIN (GAMMAGARD LIQUID) IV NON-LYOPHIL J1570 INJ GANCICLOVIR SODIUM 500 MG J1571 INJ HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B) IM 0.5 M J1572 INJ IMMUNE GLOBULIN (FLEBOGAMMA) IV NON-LYOPHILIZED J1573 INJ HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B) IV 0.5 ML J1580 INJ GARAMYCIN GENTAMICIN UP TO 80 MG J1595 INJ GLATIRAMER ACETATE 20 MG J1600 INJ GOLD SODIUM THIOMALATE UP TO 50 MG J1610 INJ GLUCAGON HCL PER 1 MG J1620 INJ GONADORELIN HCL PER 100 MCG J1625 INJ GRANISETRON HCL PER 1 MG J1626 INJ GRANISETRON HCL 100 MCG J1630 INJ HALOPERIDOL UP TO 5 MG J1631 INJ HALOPERIDOL DECANOATE PER 50 MG J1640 INJ HEMIN 1 MG J1642 INJ HEPARIN SODIUM (HEPARIN LOCK FLUSH) PER 10 UNITS J1644 INJ HEPARIN SODIUM PER 1000 UNITS J1645 INJ DALTEPARIN SODIUM PER 2500 IU J1650 INJ ENOXAPARIN SODIUM 10 MG J1652 INJ FONDAPARINUX SODIUM 0.5 MG J1655 INJ TINZAPARIN SODIUM 1000 IU J1670 INJ TETANUS IMMUNE GLOBULIN HUMAN UP TO 250 UNITS J1675 INJ HISTRELIN ACETATE 10 MICROGRAMS J1700 INJ HYDROCORTISONE ACETATE UP TO 25 MG J1710 INJ HYDROCORTISONE SODIUM PHOSPHATE UP TO 50 MG J1720 INJ HYDROCORTISONE SODIUM SUCCINATE UP TO 100 MG J1730 INJ DIAZOXIDE UP TO 300 MG J1740 INJ IBANDRONATE SODIUM 1 MG J1742 INJ IBUTILIDE FUMARATE 1 MG J1743 INJ IDURSULFASE 1 MG J1745 INJ INFLIXIMAB 10 MG J1751 INJ, IRON DEXTRAN 165, 50 MG J1752 INJ, IRON DEXTRAN 267, 50 MG J1756 INJ, IRON SUCROSE, 1 MG J1785 INJ IMIGLUCERASE PER UNIT J1790 INJ DROPERIDOL UP TO 5 MG J1800 INJ PROPRANOLOL HCL UP TO 1 MG J1810 INJ DROPERIDOL AND FENTANYL CITRATE UP TO 2 ML AMPULE Page 4 of 12 February 8, 2008

7 J1815 INJ INSULIN PER 5 UNITS J1825 INJ INTERFERON BETA-1A 33 MCG J1835 INJ ITRACONAZOLE 50 MG J1840 INJ KANAMYCIN SULFATE UP TO 500 MG J1850 INJ KANAMYCIN SULFATE UP TO 75 MG J1885 INJ KETOROLAC TROMETHAMINE PER 15 MG J1890 INJ CEPHALOTHIN SODIUM UP TO 1 GRAM J1931 INJ LARONIDASE 0.1 MG J1940 INJ FUROSEMIDE UP TO 20 MG J1945 INJ LEPIRUDIN 50 MG J1950 INJ LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION) PER 3.75 MG J1955 INJ LEVOCARNITINE PER 1 GM J1956 INJ LEVOFLOXACIN 250 MG J1960 INJ LEVORPHANOL TARTRATE UP TO 2 MG J1980 INJ HYOSCYAMINE SULFATE UP TO 0.25 MG J1990 INJ CHLORDIAZEPOXIDE HCL UP TO 100 MG J2001 INJ LIDOCAINE HCL FOR IV INFUSION 10 MG J2010 INJ LINCOMYCIN HCL UP TO 300 MG J2020 INJ LINEZOLID 200MG J2060 INJ LORAZEPAM 2 MG J2150 INJ MANNITOL 25% IN 50 ML J2170 INJ MECASERMIN 1 MG J2175 INJ MEPERIDINE HCL PER 100 MG J2180 INJ MEPERIDINE AND PROMETHAZINE HCL UP TO 50 MG J2185 INJ MEROPENEM 100 MG J2210 INJ METHYLERGONOVINE MALEATE UP TO 0.2 MG J2248 INJ MICAFUNGIN SODIUM 1 MG J2250 INJ MIDAZOLAM HCL PER 1 MG J2260 INJ MILRINONE LACTATE 5 MG J2270 INJ MORPHINE SULFATE UP TO 10 MG J2271 INJ MORPHINE SULFATE 100MG J2275 INJ MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION) PER 10 J2278 INJ ZICONOTIDE 1 MICROGRAM J2280 INJ MOXIFLOXACIN 100 MG J2300 INJ NALBUPHINE HCL PER 10 MG J2310 INJ NALOXONE HCL PER 1 MG J2315 INJ NALTREXONE DEPOT FORM 1 MG J2320 INJ NANDROLONE DECANOATE UP TO 50 MG J2321 INJ NANDROLONE DECANOATE UP TO 100 MG J2322 INJ NANDROLONE DECANOATE UP TO 200 MG J2323 INJ NATALIZUMAB 1 MG J2325 INJ NESIRITIDE 0.1 MG J2353 INJ OCTREOTIDE DEPOT FORM FOR IM INJ 1 MG J2354 INJ OCTREOTIDE NON-DEPOT FORM FOR SUBQ OR IV J2355 INJ OPRELVEKIN 5 MG J2357 INJ OMALIZUMAB 5 MG J2360 INJ ORPHENADRINE CITRATE UP TO 60 MG J2370 INJ PHENYLEPHRINE HCL UP TO 1 ML J2400 INJ CHLOROPROCAINE HCL PER 30 ML J2405 INJ ONDANSETRON HCL PER 1 MG J2410 INJ OXYMORPHONE HCL UP TO 1 MG J2425 INJ PALIFERMIN 50 MICROGRAMS Page 5 of 12 February 8, 2008

8 J2430 INJ PAMIDRONATE DISODIUM PER 30 MG J2469 INJ PALONOSETRON HCL 25 MCG J2501 INJ PARICALCITOL 1 MCG J2503 INJ PEGAPTANIB SODIUM 0.3 MG J2504 INJ PEGADEMASE BOVINE 25 IU J2505 INJ PEGFILGRASTIM 6 MG J2510 INJ PENICILLIN G PROCAINE AQUEOUS UP TO UNITS J2513 INJ PENTASTARCH 10% SOLUTION 100 ML J2515 INJ PENTOBARBITAL SODIUM PER 50 MG J2540 INJ PENICILLIN G POTASSIUM UP TO UNITS J2543 INJ PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 1 GRAM/0.125 GRAMS (1. J2545 PENTAMIDINE ISETHIONATE INH SOLUTION J2550 INJ PROMETHAZINE HCL UP TO 50 MG J2560 INJ PHENOBARBITAL SODIUM UP TO 120 MG J2590 INJ OXYTOCIN UP TO 10 UNITS J2597 INJ DESMOPRESSIN ACETATE PER 1 MCG J2650 INJ PREDNISOLONE ACETATE UP TO 1 ML J2670 INJ TOLAZOLINE HCL UP TO 25 MG J2675 INJ PROGESTERONE PER 50 MG J2680 INJ FLUPHENAZINE DECANOATE UP TO 25 MG J2690 INJ PROCAINAMIDE HCL UP TO 1 GM J2700 INJ OXACILLIN SODIUM UP TO 250 MG J2710 INJ NEOSTIGMINE METHYLSULFATE UP TO 0.5 MG J2720 INJ PROTAMINE SULFATE PER 10 MG J2724 INJ PROTEIN C CONCENTRATE IV HUMAN 10 IU J2725 INJ PROTIRELIN PER 250 MCG J2730 INJ PRALIDOXIME CHLORIDE UP TO 1 GM J2760 INJ PHENTOLAMINE MESYLATE UP TO 5 MG J2765 INJ METOCLOPRAMIDE HCL UP TO 10 MG J2770 INJ QUINUPRISTIN/DALFOPRISTIN 500 MG (150/350) J2778 INJ RANIBIZUMAB 0.1 MG J2780 INJ RANITIDINE HCL 25 MG J2783 INJ RASBURICASE 0.5 MG J2788 INJ RHO D IMMUNE GLOBULIN HUMAN MINIDOSE 50 MCG J2790 INJ RHO D IMMUNE GLOBULIN HUMAN FULL DOSE 300 MCG J2791 INJ RHO(D) IMMUNE GLOBULIN (HUMAN) (RHOPHYLAC) IM OR J2792 INJ RHO D IMMUNE GLOBULIN IV HUMAN SOLVENT DETERGENT J2794 INJ RISPERIDONE LONG ACTING 0.5 MG J2795 INJ ROPIVACAINE HCL 1 MG J2800 INJ METHOCARBAMOL UP TO 10 ML J2810 INJ THEOPHYLLINE PER 40 MG J2820 INJ SARGRAMOSTIM (GM-CSF) 50 MCG J2850 INJ SECRETIN SYNTHETIC HUMAN 1 MICROGRAM J2910 INJ AUROTHIOGLUCOSE UP TO 50 MG J2916 INJ SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJ 12.5 MG J2920 INJ METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG J2930 INJ METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 125 MG J2950 INJ PROMAZINE HCL UP TO 25 MG J2993 INJ RETEPLASE 18.1 MG J2995 INJ STREPTOKINASE PER IU J2997 INJ ALTEPLASE RECOMBINANT 1 MG J3000 INJ STREPTOMYCIN UP TO 1 GM Page 6 of 12 February 8, 2008

9 J3010 J3030 J3070 J3100 J3105 J3110 J3120 J3130 J3140 J3150 J3230 J3240 J3243 J3246 J3250 J3260 J3265 J3285 J3301 J3302 J3303 J3305 J3310 J3315 J3320 J3350 J3360 J3364 J3365 J3370 J3396 J3400 J3410 J3411 J3415 J3420 J3430 J3465 J3470 J3471 J3472 J3473 J3475 J3480 J3485 J3486 J3487 J3488 J3520 J3590 J7030 J7040 INJ FENTANYL CITRATE 0.1 MG INJ SUMATRIPTAN SUCCINATE 6 MG INJ PENTAZOCINE 30 MG INJ TENECTEPLASE 50MG INJ TERBUTALINE SULFATE UP TO 1 MG INJ TERIPARATIDE 10 MCG INJ TESTOSTERONE ENANTHATE UP TO 100 MG INJ TESTOSTERONE ENANTHATE UP TO 200 MG INJ TESTOSTERONE SUSPENSION UP TO 50 MG INJ TESTOSTERONE PROPIONATE UP TO 100 MG INJ CHLORPROMAZINE HCL UP TO 50 MG INJ THYROTROPIN ALPHA 0.9 MG PROVIDED IN 1.1 MG VIAL INJ TIGECYCLINE 1 MG INJ TIROFIBAN HCL 0.25MG INJ TRIMETHOBENZAMIDE HCL UP TO 200 MG INJ TOBRAMYCIN SULFATE UP TO 80 MG INJ TORSEMIDE 10 MG/ML INJ TREPROSTINIL 1 MG INJ TRIAMCINOLONE ACETONIDE PER 10MG INJ TRIAMCINOLONE DIACETATE PER 5MG INJ TRIAMCINOLONE HEXACETONIDE PER 5MG INJ TRIMETREXATE GLUCURONATE PER 25 MG INJ PERPHENAZINE UP TO 5 MG INJ TRIPTORELIN PAMOATE 3.75 MG INJ SPECTINOMYCIN DIHCL UP TO 2 GM INJ UREA UP TO 40 GM INJ DIAZEPAM UP TO 5 MG INJ UROKINASE 5000 IU VIAL INJ IV UROKINASE I.U. VIAL INJ VANCOMYCIN HCL 500 MG INJ VERTEPORFIN 0.1 MG INJ TRIFLUPROMAZINE HCL UP TO 20 MG INJ HYDROXYZINE HCL UP TO 25 MG INJ THIAMINE HCL 100 MG INJ PYRIDOXINE HCL 100 MG INJ VITAMIN B-12 CYANOCOBALAMIN UP TO 1000 MCG INJ PHYTONADIONE (VITAMIN K) PER 1 MG INJ VORICONAZOLE 10 MG INJ HYALURONIDASE UP TO 150 UNITS INJ HYALURONIDASE OVINE PRESERVATIVE FREE PER 1 USP UNIT (UP T INJ HYALURONIDASE OVINE PRESERVATIVE FREE PER 1000 USP UNITS INJ HYALURONIDASE RECOMBINANT 1 USP UNIT INJ MAGNESIUM SULFATE PER 500 MG INJ POTASSIUM CHLORIDE PER 2 MEQ INJ ZIDOVUDINE 10 MG INJ ZIPRASIDONE MESYLATE 10 MG INJ ZOLEDRONIC ACID (ZOMETA) 1 MG INJ ZOLEDRONIC ACID (RECLAST) 1 MG EDETATE DISODIUM PER 150 MG UNCLASSIFIED BIOLOGICS INFUSION NORMAL SALINE SOLUTION 1000 CC INFUSION NORMAL SALINE SOLUTION STERILE (500 ML=1 UNIT) Page 7 of 12 February 8, 2008

10 J7042 J7050 J7060 J7070 J7100 J7110 J7120 J7130 J7187 J7189 J7190 J7192 J7193 J7194 J7197 J7198 J7302 J7303 J7304 J7306 J7307 J7308 J7310 J7311 J7500 J7501 J7502 J7504 J7505 J7506 J7507 J7509 J7510 J7511 J7513 J7515 J7516 J7517 J7518 J7520 J7525 J7602 J7603 J7605 J7608 J7620 J7626 J7631 J7633 J7639 J7644 J7648 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) INFUSION NORMAL SALINE SOLUTION 250 CC 5% DEXTROSE/WATER (500 ML = 1 UNIT) INFUSION D5W 1000 CC INFUSION DEXTRAN ML INFUSION, DEXTRAN 75, 500 ML RINGERS LACTATE INFUSION UP TO 1000 CC HYPERTONIC SALINE SOLUTION 50 OR 100 MEQ 20 CC VIAL INJ VON WILLEBRAND FACTOR COMPLEX (HUMATE-P) PER IU VWF:RCO FACTOR VIIA (ANTIHEMOPHILIC FACTOR RECOMBINANT) PER 1 MICROGRAM FACTOR VIII (ANTIHEMOPHILIC FACTOR HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR RECOMBINANT) PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR PURIFIED NON-RECOMBINANT) PER I.U. FACTOR IX COMPLEX PER I.U. ANTITHROMBIN III (HUMAN) PER I.U. ANTI-INHIBITOR PER I.U. LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG CONTRACEPTIVE SUPPLY HORMONE CONTAINING VAGINAL RING EACH CONTRACEPTIVE SUPPLY HORMONE CONTAINING PATCH EACH LEVONORGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANTS AND SU ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPL AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION 20% SINGLE UNIT DOS GANCICLOVIR 4.5 MG LONG-ACTING IMPLANT FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT AZATHIOPRINE ORAL 50 MG AZATHIOPRINE PARENTERAL 100 MG CYCLOSPORINE, ORAL, 100 MG LYMPHOCYTE IMMUNE GLOBULIN ANTITHYMOCYTE GLOBULIN EQUINE PARENTERAL MUROMONAB-CD3 PARENTERAL 5 MG PREDNISONE ORAL PER 5MG TACROLIMUS ORAL PER 1 MG METHYLPREDNISOLONE ORAL PER 4 MG PREDNISOLONE ORAL PER 5 MG LYMPHOCYTE IMMUNE GLOBULIN ANTITHYMOCYTE GLOBULIN RABBIT PARENTERAL DACLIZUMAB PARENTERAL 25 MG 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 ALBUTEROL ALL FORMULATIONS INCLUDING SEPARATED ISOMERS INH SOLU ALBUTEROL ALL FORMULATIONS INCLUDING SEPARATED ISOMERS INH SOLU ARFORMOTEROL INH SOLUTION ACETYLCYSTEINE INH SOLUTION ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, BUDESONIDE INH SOLUTION CROMOLYN SODIUM INH SOLUTION BUDESONIDE INH SOLUTION DORNASE ALPHA INH SOLUTION IPRATROPIUM BROMIDE INH SOLUTION ISOETHARINE HCL INH SOLUTION Page 8 of 12 February 8, 2008

11 J7649 J7658 J7659 J7668 J7669 J7674 J7682 J8501 J8510 J8515 J8520 J8521 J8530 J8540 J8560 J8565 J8600 J8610 J8650 J8700 J9000 J9001 J9010 J9015 J9017 J9020 J9025 J9027 J9031 J9035 J9040 J9041 J9045 J9050 J9055 J9060 J9062 J9065 J9070 J9080 J9090 J9091 J9092 J9093 J9094 J9095 J9096 J9097 J9098 J9100 J9110 J9120 ISOETHARINE HCL INH SOLUTION ISOPROTERENOL HCL INH SOLUTION ISOPROTERENOL HCL INH SOLUTION METAPROTERENOL SULFATE INH SOLUTION METAPROTERENOL SULFATE INH SOLUTION METHACHOLINE CHLORIDE ADMINISTERED AS INH SOLUTION THRU A NEBU TOBRAMYCIN INH SOLUTION APREPITANT ORAL 5 MG BUSULFAN; ORAL 2 MG CABERGOLINE ORAL 0.25 MG CAPECITABINE ORAL 150 MG CAPECITABINE ORAL 500 MG CYCLOPHOSPHAMIDE; ORAL 25 MG DEXAMETHASONE ORAL 0.25 MG ETOPOSIDE; ORAL 50 MG GEFITINIB ORAL 250 MG MELPHALAN; ORAL 2 MG METHOTREXATE; ORAL 2.5 MG NABILONE ORAL 1 MG TEMOZOLOMIDE ORAL 5 MG DOXORUBICIN HCL 10 MG DOXORUBICIN HCL ALL LIPID FORMULATIONS 10 MG ALEMTUZUMAB 10 MG ALDESLEUKIN PER SINGLE USE VIAL ARSENIC TRIOXIDE 1MG ASPARAGINASE UNITS INJ AZACITIDINE 1 MG INJ CLOFARABINE 1 MG BCG (INTRAVESICAL) PER INSTILLATION INJ BEVACIZUMAB 10 MG BLEOMYCIN SULFATE 15 UNITS INJ BORTEZOMIB 0.1 MG CARBOPLATIN 50 MG CARMUSTINE 100 MG INJ CETUXIMAB 10 MG CISPLATIN POWDER OR S0LUTION PER 10 MG CISPLATIN 50 MG INJ CLADRIBINE PER 1 MG CYCLOPHOSPHAMIDE 100 MG CYCLOPHOSPHAMIDE 200 MG CYCLOPHOSPHAMIDE 500 MG CYCLOPHOSPHAMIDE 1.0 GRAM CYCLOPHOSPHAMIDE 2.0 GRAM CYCLOPHOSPHAMIDE LYOPHILIZED 100 MG CYCLOPHOSPHAMIDE LYOPHILIZED 200 MG CYCLOPHOSPHAMIDE LYOPHILIZED 500 MG CYCLOPHOSPHAMIDE LYOPHILIZED 1.0 GRAM CYCLOPHOSPHAMIDE LYOPHILIZED 2.0 GRAM CYTARABINE LIPOSOME 10 MG CYTARABINE 100 MG CYTARABINE 500 MG DACTINOMYCIN 0.5 MG Page 9 of 12 February 8, 2008

12 J9130 J9140 J9150 J9151 J9160 J9165 J9170 J9175 J9178 J9181 J9182 J9185 J9190 J9200 J9201 J9202 J9206 J9208 J9209 J9211 J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9225 J9226 J9230 J9245 J9250 J9260 J9261 J9263 J9264 J9265 J9266 J9268 J9270 J9280 J9290 J9291 J9293 J9300 J9303 J9305 J9310 J9320 J9340 J9350 DACARBAZINE 100 MG DACARBAZINE 200 MG DAUNORUBICIN 10 MG DAUNORUBICIN CITRATE LIPOSOMAL FORMULATION 10 MG DENILEUKIN DIFTITOX 300 MCG DIETHYLSTILBESTROL DIPHOSPHATE 250 MG DOCETAXEL 20 MG INJ ELLIOTTS' B SOLUTION 1 ML INJ EPIRUBICIN HCL 2 MG ETOPOSIDE 10 MG ETOPOSIDE 100 MG FLUDARABINE PHOSPHATE 50 MG FLUOROURACIL 500 MG FLOXURIDINE 500 MG GEMCITABINE HCL 200 MG GOSERELIN ACETATE IMPLANT PER 3.6 MG IRINOTECAN 20 MG IFOSFAMIDE 1 GM MESNA 200 MG IDARUBICIN HCL 5 MG INJ INTERFERON ALFACON-1 RECOMBINANT 1 MCG INTERFERON ALFA-2A RECOMBINANT 3 MILLION UNITS INTERFERON ALFA-2B RECOMBINANT 1 MILLION UNITS INTERFERON ALFA-N3 (HUMAN LEUKOCYTE DERIVED) IU INTERFERON GAMMA 1-B 3 MILLION UNITS LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION) 7.5 MG LEUPROLIDE ACETATE PER 1 MG LEUPROLIDE ACETATE IMPLANT 65 MG HISTRELIN IMPLANT (VANTAS) 50 MG HISTRELIN IMPLANT (SUPPRELIN LA) 50 MG MECHLORETHAMINE HCL (NITROGEN MUSTARD) 10 MG INJ MELPHALAN HCL 50 MG METHOTREXATE SODIUM 5 MG METHOTREXATE SODIUM 50 MG INJ NELARABINE 50 MG INJ OXALIPLATIN 0.5 MG INJ PACLITAXEL PROTEIN-BOUND PARTICLES 1 MG PACLITAXEL 30 MG PEGASPARGASE PER SINGLE DOSE VIAL PENTOSTATIN PER 10 MG PLICAMYCIN 2.5 MG MITOMYCIN 5 MG MITOMYCIN 20 MG MITOMYCIN 40 MG INJ MITOXANTRONE HCL PER 5 MG GEMTUZUMAB OZOGAMICIN 5MG INJ PANITUMUMAB 10 MG INJ PEMETREXED 10 MG RITUXIMAB 100 MG STREPTOZOCIN 1 GM THIOTEPA 15 MG TOPOTECAN 4 MG Page 10 of 12 February 8, 2008

13 J9355 J9357 J9360 J9370 J9375 J9380 J9390 J9395 J9600 Q0144 Q0163 Q0164 Q0165 Q0166 Q0167 Q0168 Q0169 Q0170 Q0171 Q0172 Q0175 Q0176 Q0177 Q0178 Q0179 Q0180 Q2004 Q2009 Q2017 Q3025 Q3026 Q4081 Q0515 S0017 S0020 S0021 S0023 S0028 S0030 S0032 S0034 S0039 S0040 S0073 S0074 S0077 S0078 S0080 S0081 S0092 S0093 S0104 TRASTUZUMAB 10 MG VALRUBICIN INTRAVESICAL 200 MG VINBLASTINE SULFATE 1 MG VINCRISTINE SULFATE 1 MG VINCRISTINE SULFATE 2 MG VINCRISTINE SULFATE 5 MG VINORELBINE TARTRATE PER 10 MG INJ FULVESTRANT 25 MG PORFIMER SODIUM 75 MG AZITHROMYCIN DIPHENHYDRAMINE HCL 50 MG ORAL PROCHLORPERAZINE MALEATE 5 MG ORAL PROCHLORPERAZINE MALEATE 10 MG ORAL GRANISETRON HCL 1 MG ORAL DRONABINOL 2.5 MG ORAL DRONABINOL 5 MG ORAL PROMETHAZINE HCL 12.5 MG ORAL PROMETHAZINE HCL 25 MG ORAL CHLORPROMAZINE HCL 10 MG ORAL CHLORPROMAZINE HCL 25 MG ORAL PERPHENAZINE 4 MG ORAL PERPHENAZINE 8 MG ORAL HYDROXYZINE PAMOATE 25 MG ORAL HYDROXYZINE PAMOATE 50 MG ORAL ONDANSETRON HCL 8 MG ORAL DOLASETRON MESYLATE 100 MG ORAL IRRIGATION SOLUTION FOR BLADDER CALCULI INJ, FOSPHENYTOIN, 50 MG INJ, TENIPOSIDE, 50 MG INTERFERON BETA 1-A 11 MCG INJ FOR IM USE INJ, INTERFERON BETA-1A, 11 MCG INJ, EPOETIN ALFA, 100 UNITS INJ, SERMORELIN ACETATE, 1 MICROGRAM INJ AMINOCAPROIC ACID 5 GRAMS INJ BUPIVICAINE HCL 30 ML INJ CEFOPERAZONE SODIUM 1 GRAM INJ CIMETIDINE HCL 300 MG INJ FAMOTIDINE 20 MG INJ METRONIDAZOLE 500 MG INJ NAFCILLIN SODIUM 2 GRAMS INJ OFLOXACIN 400 MG INJ SULFAMETHOXAZOLE AND TRIMETHOPRIM 10 ML INJ TICARCILLIN DISODIUM & CLAVULANATE POTASSIUM 3.1 GRAMS INJ AZTREONAM 500 MG INJ CEFOTETAN DISODIUM 500 MG INJ CLINDAMYCIN PHOSPHATE 300 MG INJ FOSPHENYTOIN SODIUM 750 MG INJ PENTAMIDINE ISETHIONATE 300 MG INJ PIPERACILLIN SODIUM 500 MG INJ HYDROMORPHONE HCL 250 MG INJ MORPHINE SULFATE 500 MG ZIDOVUDINE ORAL 100 MG Page 11 of 12 February 8, 2008

14 S0108 S0137 S0142 S0143 S0145 S0146 S0155 S0156 S0157 S0162 S0164 S0171 S0172 S0176 S0178 S0179 S0182 S0189 S0190 S0191 S5010 S5011 S5012 S5013 S5014 S5550 S5551 S5552 S5553 S5565 S5566 S5570 S5571 MERCAPTOPURINE ORAL 50 MG DIDANOSINE (DDI) 25 MG COLISTIMETHATE SODIUM, INH SOLUTION AZTREONAM, INH SOLUTION INJ PEGYLATED INTERFERON ALFA-2A 180 MCG PER ML INJ PEGYLATED INTERFERON ALFA-2B 10 MCG PER 0.5 ML STERILE DILUTANT FOR EPOPROSTENOL, 50ML EXEMESTANE, 25 MG BECAPLERMIN GEL 0.01% 0.5 GM INJ EFALIZUMAB 125 MG INJ PANTOPRAZOLE SODIUM 40 MG INJ BUMETANIDE 0.5MG CHLORAMBUCIL ORAL 2MG HYDROXYUREA ORAL 500MG LOMUSTINE ORAL 10MG MEGESTROL ACETATE, ORAL, 20MG PROCARBAZINE HCL ORAL 50MG TESTOSTERONE PELLET 75MG MIFEPRISTONE ORAL 200 MG MISOPROSTOL ORAL 200 MCG 5% DEXTROSE AND 0.45% NORMAL SALINE 1000 ML 5% DEXTROSE IN LACTATED RINGER'S 1000 ML 5% DEXTROSE WITH POTASSIUM CHLORIDE 1000 ML 5% DEXTROSE/0.45% NORMAL SALINE WITH KCL AND MAG 5% DEXTROSE/0.45% NORMAL SALINE WITH KCL AND MAG 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 CARTRIDGE INSULIN DELIVERY DEVICE OTHER THAN PUMP; 150 UNITS INSULIN CARTRIDGE INSULIN DELIVERY DEVICE OTHER THAN PUMP; 300 UNITS INSULIN DELIVERY DEVICE DISPOSABLE PEN (INCLUDING INSULIN); 1.5 ML SIZE INSULIN DELIVERY DEVICE DISPOSABLE PEN (INCLUDING INSULIN); 3 ML SIZE Page 12 of 12 February 8, 2008