NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only
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- Harvey Carpenter
- 8 years ago
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1 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN ZEVALIN Y-90 VIAL 9/1/ /31/ A9581 INJECTION, GADOXETATE DISODIUM, 1 ML EOVIST 2.5 MMOL/10 ML VIAL 10/1/ /99/ J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 0.1 MG/ML SYRINGE 1/1/ /99/ J0171 ADRENALIN EPINEPHRINE INJECT ADRENALIN CL 1 MG/ML VIAL 1/1/ /99/ J0171 ADRENALIN EPINEPHRINE INJECT EPIPEN 2-PAK 0.3 MG AUTO-INJCT 1/1/ /99/ J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/ /99/ J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/ /99/ J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/ /99/ J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/ J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/ J0221 LUMIZYME INJECTION LUMIZYME 50 MG VIAL 1/1/ /99/ J0257 GLASSIA INJECTION GLASSIA 1 GM/50 ML VIAL 1/1/ /99/ J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 1 MG/ML VIAL 3/1/ /99/ J0490 BELIMUMAB INJECTION BENLYSTA 120 MG VIAL 1/1/ /99/9999 Y J0490 BELIMUMAB INJECTION BENLYSTA 400 MG VIAL 1/1/ /99/9999 Y J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 600,000 UNIT/ML 1/1/ /99/ J0561 PENICILLIN G BENZATHINE INJ PEN G 1.2 MILLION UNIT/2 ML 1/1/ /99/ J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 1,200,000 UNITS 1/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 300 UNIT VIAL 4/1/2012 3/31/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 500 UNITS VIAL 4/1/2012 3/31/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 100 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/ /31/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 200 UNITS VIAL 4/1/ /99/ J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 500 UNITS VIAL 4/1/ /99/ J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 300 UNIT VIAL 4/1/ /99/ J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 2,500 UNIT/0.5 ML VIAL 2/1/ /99/ J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 5,000 UNITS/1 ML VIAL 2/1/ /99/ J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 10,000 UNITS/2 ML VIAL 2/1/ /99/ J0588 INCOBOTULINUMTOXIN A XEOMIN 50 UNITS VIAL 1/1/ /99/ J0588 INCOBOTULINUMTOXIN A XEOMIN 100 UNITS VIAL 1/1/ /99/ J0598 C-1 ESTERASE, CINRYZE BERINERT 500 UNIT KIT 2/1/ /99/ J0638 CANAKINUMAB INJECTION ILARIS 180 MG VIAL 1/1/ /99/9999
2 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 2/15/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 2/15/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 50 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 8/31/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 4/30/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 5/31/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 6/30/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 500 MG VL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 8/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 12/30/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/2/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 11/9/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 5/29/2008 1/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 4/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 5/29/2008 1/31/2013
3 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 5/29/2008 1/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 5/29/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 1/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 2 GM VIAL 3/1/2008 8/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 10 GM VIAL 3/1/2008 8/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM-D5W BAG 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM-D5W BAG 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 7/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2013
4 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011
5 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 2/28/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 8/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 6/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 7/17/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 8/16/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/ J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 400 MG VIAL 1/1/ /99/ J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 600 MG VIAL 1/1/ /99/ J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG CORTROSYN 0.25 MG VIAL 1/1/ /99/ J0840 CROTALIDAE POLY IMMUNE FAB CROFAB VIAL 1/1/2012 6/30/ J0886 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 5/1/ /99/ J0897 DENOSUMAB INJECTION XGEVA 120 MG/1.7 ML VIAL 1/1/ /99/ J0897 DENOSUMAB INJECTION PROLIA 60 MG/ML SYRINGE 1/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/ /99/9999
6 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/2/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/16/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/16/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/30/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 8/30/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/30/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 2/28/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 3/31/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE INTENSOL 1MG/1ML 3/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML VL 11/10/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 50 MG/5 ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 500 MG/50 ML VIA 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/ /99/9999
7 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 250 MG VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/1/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML VIAL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 1 MG/ML SYRINGE 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 4 MG/ML SYRIN 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML SYRINGE 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 7/1/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 9/30/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 4 MG/ML AMP 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 1 MG/ML AMP 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 2 MG/ML AMP 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 8/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 9/30/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 6/30/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/ /99/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/ /99/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 9/30/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 7/1/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/ /99/ J1453 FOSAPREPITANT INJECTION EMEND 150 MG VIAL 11/15/ /99/9999
8 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1453 FOSAPREPITANT INJECTION EMEND 115 MG VIAL 11/1/2009 7/31/ J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/ /99/ J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/ /99/ J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN FLEBOGAMMA DIF 10% VIAL 2/8/ /99/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 G (IGA<1) SOLN 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 G (IGA<1) SOL 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 5 GM VIAL-DILUE 3/1/ /31/ J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 10 GM VIAL-DILU 3/1/ /31/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 0.5 GM VL W-ST 3/1/ /31/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 2.5 GM VL W/ST 3/1/2010 5/25/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 GM VL W/SET 3/1/2010 4/11/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 GM VL W/ST 3/1/2010 6/21/ J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 3 GM VIAL 3/1/2010 6/3/ J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 6 GM VIAL 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 12 GM VIAL 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN IVEEGAM EN 5 GM VIAL 3/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 2/8/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 11/15/ /99/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 9/30/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/ /31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 1/1/ /99/9999
9 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 1/1/2010 8/31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/ /31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 6/28/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 1 MG/ML VIAL 6/1/2009 7/31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 4 MG/4 ML VIAL 6/1/ /30/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 0.1 MG/ML VIAL 6/1/2009 3/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 100 AMPUL 3/1/2008 5/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1725 HYDROXYPROGESTERONE CAPROATE MAKENA 250 MG/ML VIAL 1/1/ /99/ J1725 HYDROXYPROGESTERONE CAPROATE PROGESTERONE OIL 50 MG/ML VL 1/1/ /99/ J1750 INJECTION, IRON DEXTRAN INFED 100 MG/2 ML VIAL 1/1/ /99/ J1750 INJECTION, IRON DEXTRAN VENOFER 100 MG/5 ML VIAL 1/1/ /99/ J1750 INJECTION, IRON DEXTRAN DEXFERRUM 100 MG/2 ML VIAL 1/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 5/15/2009 5/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML ISECURE SYR 3/1/2008 4/1/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2ML ISECURE 3/1/ /1/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/ /99/9999
10 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML ISECURE SYR 3/1/ /31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML CARPUJECT 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 9/30/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 7/1/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML SYRINGE 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML SYRINGE 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC IM 30 MG/ML SYRING 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 5/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 8/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 300 MG/10 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KENALOG MG/ML VIAL 3/1/ /99/ J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT MG 3MO KIT 1/1/ /99/ J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 22.5 MG 3MO KIT 1/1/ /99/ J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 3.75 MG KIT 1/1/ /99/9999
11 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2315 INJECTION, NALTREXONE, DEPOT FORM, 1 MG VIVITROL 380 MG VIAL + DILUENT 7/1/ /99/ J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 10 MG KIT 11/1/ /99/ J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 20 MG KIT 11/1/ /99/ J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 30 MG KIT 11/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 8/29/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 9/9/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 8 MG TABLET 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 2/8/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 2 MG/ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 4 MG/2 ML VIAL 6/1/2009 3/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 32 MG/50 ML BAG 6/1/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML SYR 6/1/2009 3/1/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 6/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /10/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 8/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 1/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 7/31/2013
12 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/24/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG TABLET 6/1/2009 1/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 2/26/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 1/1/2010 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 11/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 3/8/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG KETOROLAC 30 MG/ML VIAL 6/1/ /99/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 2/26/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 30 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 90 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIA 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIA 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 2/28/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 5/31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 3/31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 3/31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/ /31/2010
13 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 60 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 3 MG/ML VIA 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 9 MG/ML VIA 3/1/2008 3/31/ J2507 PEGLOTICASE INJECTION KRYSTEXXA 8 MG/ML VIAL 1/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 4.5 GM VIAL 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 11/8/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 11/8/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 2/8/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 2/6/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 1/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2/0.25 GM ADD-VANTAGE VL 4/1/2008 3/31/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GRAM VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3/0.375 GM ADD-VANTAGE 4/1/2008 6/30/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GRAM VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4/0.5 GM ADD-VANTAGE VL 4/1/2008 6/30/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 40.5 GRAM BULK VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GM/50 ML GALAXY BAG 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GM/50 ML GALAXY 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GRAM VIAL 7/19/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GRAM VIAL 5/29/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 12/30/ /99/9999
14 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 12/30/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 9/2/2008 1/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 5/29/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 8/16/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML SYRINGE 3/1/ /31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/2/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 6/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 6/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 3/1/2008 1/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 3/1/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 3/1/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 3/1/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML VIAL 3/1/ /31/2012
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