NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 68152-0103-03 A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN ZEVALIN Y-90 VIAL 9/1/2013 12/31/2013 50419-0320-05 A9581 INJECTION, GADOXETATE DISODIUM, 1 ML EOVIST 2.5 MMOL/10 ML VIAL 10/1/2011 99/99/9999 00409-4901-18 J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 0.1 MG/ML SYRINGE 1/1/2013 99/99/9999 42023-0122-25 J0171 ADRENALIN EPINEPHRINE INJECT ADRENALIN CL 1 MG/ML VIAL 1/1/2013 99/99/9999 49502-0500-02 J0171 ADRENALIN EPINEPHRINE INJECT EPIPEN 2-PAK 0.3 MG AUTO-INJCT 1/1/2013 99/99/9999 62756-0581-40 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 99/99/9999 62756-0581-42 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 99/99/9999 55390-0308-03 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 99/99/9999 58178-0017-01 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/2013 58178-0017-03 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/2013 58468-0160-01 J0221 LUMIZYME INJECTION LUMIZYME 50 MG VIAL 1/1/2012 99/99/9999 00944-2884-01 J0257 GLASSIA INJECTION GLASSIA 1 GM/50 ML VIAL 1/1/2012 99/99/9999 00517-1010-25 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 1 MG/ML VIAL 3/1/2010 99/99/9999 49401-0101-01 J0490 BELIMUMAB INJECTION BENLYSTA 120 MG VIAL 1/1/2012 99/99/9999 Y 49401-0102-01 J0490 BELIMUMAB INJECTION BENLYSTA 400 MG VIAL 1/1/2012 99/99/9999 Y 60793-0700-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 600,000 UNIT/ML 1/1/2011 99/99/9999 60793-0131-10 J0561 PENICILLIN G BENZATHINE INJ PEN G 1.2 MILLION UNIT/2 ML 1/1/2011 99/99/9999 60793-0701-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 1,200,000 UNITS 1/1/2011 99/99/9999 15054-0530-06 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 300 UNIT VIAL 4/1/2012 3/31/2013 15054-0500-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 500 UNITS VIAL 4/1/2012 3/31/2013 00023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/2012 99/99/9999 00023-9232-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 100 UNITS VIAL 4/1/2012 99/99/9999 00023-9232-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/2012 12/31/2012 00023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/2012 99/99/9999 00023-3919-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/2012 99/99/9999 00023-3921-02 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 200 UNITS VIAL 4/1/2012 99/99/9999 15054-0500-01 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 500 UNITS VIAL 4/1/2013 99/99/9999 15054-0530-06 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 300 UNIT VIAL 4/1/2013 99/99/9999 10454-0710-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 2,500 UNIT/0.5 ML VIAL 2/1/2013 99/99/9999 10454-0711-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 5,000 UNITS/1 ML VIAL 2/1/2013 99/99/9999 10454-0712-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 10,000 UNITS/2 ML VIAL 2/1/2013 99/99/9999 00259-1605-01 J0588 INCOBOTULINUMTOXIN A XEOMIN 50 UNITS VIAL 1/1/2012 99/99/9999 00259-1610-01 J0588 INCOBOTULINUMTOXIN A XEOMIN 100 UNITS VIAL 1/1/2012 99/99/9999 63833-0825-02 J0598 C-1 ESTERASE, CINRYZE BERINERT 500 UNIT KIT 2/1/2013 99/99/9999 00078-0582-61 J0638 CANAKINUMAB INJECTION ILARIS 180 MG VIAL 1/1/2013 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 25021-0815-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 2/15/2013 99/99/9999 25021-0816-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 2/15/2013 99/99/9999 00703-5140-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 99/99/9999 00703-5145-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 99/99/9999 55390-0009-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 99/99/9999 55390-0051-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 50 MG VIAL 3/1/2008 99/99/9999 55390-0052-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 99/99/9999 55390-0053-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 99/99/9999 55390-0054-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 99/99/9999 55390-0818-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 8/31/2014 55390-0824-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 4/30/2014 55390-0825-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 5/31/2013 55390-0826-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 6/30/2013 63323-0711-00 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 500 MG VL 3/1/2008 99/99/9999 63323-0710-50 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 8/30/2011 99/99/9999 55390-0310-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 99/99/9999 25021-0104-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 12/30/2008 12/31/2010 25021-0105-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/2008 99/99/9999 25021-0106-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 12/30/2008 99/99/9999 25021-0107-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 12/30/2008 99/99/9999 00517-8711-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/2/2008 12/31/2012 00517-8722-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/2/2008 12/31/2012 00517-8725-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/2008 12/31/2012 00517-8750-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/2008 12/31/2012 68330-0005-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/2/2008 9/30/2011 55390-0309-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 11/9/2009 99/99/9999 55390-0311-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/1/2009 99/99/9999 00069-4481-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2011 00069-4481-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2011 00069-4482-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/2012 00069-4482-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/2012 00703-0315-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 5/29/2008 1/31/2013 00703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/2011 00703-0335-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 4/30/2013 00703-0346-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 5/29/2008 1/31/2013

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00703-0359-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 5/29/2008 1/31/2013 00781-3208-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 99/99/9999 68330-0006-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 5/29/2008 9/30/2011 00781-9328-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 00143-9856-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/30/2008 99/99/9999 00143-9857-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 1/1/2010 99/99/9999 00143-9858-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/2008 99/99/9999 00143-9859-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/2008 99/99/9999 00703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/2011 00004-1962-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/2008 00004-1963-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/2008 99/99/9999 00004-1963-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/2008 99/99/9999 00004-1964-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/2008 99/99/9999 00004-1964-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/2008 99/99/9999 00004-1965-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 2 GM VIAL 3/1/2008 8/31/2008 00004-1971-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 10 GM VIAL 3/1/2008 8/31/2008 00264-3153-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM-D5W BAG 3/1/2008 99/99/9999 00264-3155-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM-D5W BAG 3/1/2008 99/99/9999 00338-5002-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/2008 99/99/9999 00338-5003-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/2008 99/99/9999 00409-7332-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 00409-7333-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 00409-7333-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 00409-7334-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 00409-7335-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 00409-7336-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/2008 99/99/9999 00409-7336-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/2008 99/99/9999 00409-7337-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 00409-7338-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 00781-3206-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 00781-9326-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 7/31/2015 10019-0098-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 10019-0098-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 10019-0685-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 12/31/2011 10019-0685-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2013

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 10019-0686-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 12/31/2011 10019-0686-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2013 10019-0687-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 12/31/2011 10019-0687-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2013 10019-0688-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 10019-0688-27 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 10019-0689-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 60505-0679-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 60505-0679-08 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/2008 99/99/9999 60505-0679-09 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/2008 99/99/9999 60505-0750-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 60505-0750-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 60505-0751-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 60505-0751-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 60505-0752-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 60505-0752-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 60505-0753-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 60505-0753-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 63323-0344-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 63323-0345-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 63323-0346-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 63323-0347-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 63323-0348-61 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 68180-0611-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 68180-0611-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 68180-0622-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 68180-0622-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 68180-0633-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 68180-0633-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 68180-0644-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 68180-0644-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 68330-0001-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 68330-0001-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 68330-0002-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011 68330-0002-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 68330-0003-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2011 68330-0003-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2011 68330-0004-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/2011 68330-0004-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/2011 64679-0701-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 64679-0701-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 64679-0701-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 64679-0702-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 64679-0703-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 64679-0703-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 2/28/2010 64679-0983-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 64679-0983-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 64679-0702-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 00781-3207-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 00781-3208-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 00781-3209-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 00781-3210-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 00781-9327-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 00781-9328-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 00781-9329-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 8/31/2015 00781-9330-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 6/30/2015 00781-3206-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 7/17/2009 99/99/9999 00781-3207-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/2008 99/99/9999 00781-9326-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/30/2011 99/99/9999 00781-9327-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 8/16/2012 99/99/9999 00004-1962-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/2008 00456-0400-10 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 400 MG VIAL 1/1/2012 99/99/9999 00456-0600-10 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 600 MG VIAL 1/1/2012 99/99/9999 00548-5900-00 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG CORTROSYN 0.25 MG VIAL 1/1/2013 99/99/9999 00281-0330-10 J0840 CROTALIDAE POLY IMMUNE FAB CROFAB VIAL 1/1/2012 6/30/2013 59676-0320-04 J0886 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 5/1/2011 99/99/9999 55513-0730-01 J0897 DENOSUMAB INJECTION XGEVA 120 MG/1.7 ML VIAL 1/1/2012 99/99/9999 55513-0710-01 J0897 DENOSUMAB INJECTION PROLIA 60 MG/ML SYRINGE 1/1/2012 99/99/9999 00781-3132-95 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/2010 99/99/9999 00781-3132-71 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/2010 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00781-3137-75 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 00703-0051-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 00703-0051-04 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 00703-0063-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 00009-0306-12 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 00009-0306-02 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 00009-3475-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 00009-3073-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/2010 99/99/9999 00009-3073-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/2010 99/99/9999 00009-3475-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 00009-3475-23 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 00641-0367-21 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/2/2008 99/99/9999 00069-4541-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/16/2012 99/99/9999 00069-4543-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/16/2012 99/99/9999 00069-4543-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/30/2011 99/99/9999 00069-4545-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 8/30/2011 99/99/9999 00069-4541-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/30/2011 99/99/9999 00517-4901-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/2008 99/99/9999 00517-4905-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/2008 99/99/9999 00517-4930-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/2008 99/99/9999 00641-0367-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 99/99/9999 00703-3524-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 2/28/2011 00703-3524-03 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 3/31/2011 63323-0165-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/2008 99/99/9999 63323-0165-05 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/2008 99/99/9999 63323-0165-30 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/2008 99/99/9999 63323-0506-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 99/99/9999 63323-0516-10 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 3/1/2008 99/99/9999 00054-3176-44 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE INTENSOL 1MG/1ML 3/1/2008 99/99/9999 17478-0540-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML VL 11/10/2010 99/99/9999 00409-2634-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 99/99/9999 00409-2634-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 50 MG/5 ML VIAL 6/1/2009 99/99/9999 00409-2634-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 500 MG/50 ML VIA 6/1/2009 99/99/9999 59011-0441-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 99/99/9999 59011-0442-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 59011-0442-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 99/99/9999 59011-0444-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 99/99/9999 59011-0445-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/2009 99/99/9999 59011-0445-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/2009 99/99/9999 59011-0445-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML VIAL 6/1/2009 99/99/9999 59011-0446-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 250 MG VIAL 6/1/2009 99/99/9999 00074-2332-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 3/31/2011 00074-2333-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/31/2011 00074-2333-26 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/1/2011 00074-2334-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 3/31/2011 00074-2414-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML VIAL 6/1/2009 3/31/2010 00406-3245-52 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 00409-1283-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 1 MG/ML SYRINGE 6/1/2009 99/99/9999 00409-1304-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 4 MG/ML SYRIN 6/1/2009 99/99/9999 00409-1312-30 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML SYRINGE 6/1/2009 99/99/9999 00409-2172-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 7/1/2011 00409-2172-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 9/30/2011 00409-2540-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 4 MG/ML AMP 6/1/2009 99/99/9999 00409-2552-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 1 MG/ML AMP 6/1/2009 99/99/9999 00409-3356-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 2 MG/ML AMP 6/1/2009 99/99/9999 00409-3365-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 00555-1117-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 8/31/2011 00555-1117-06 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 9/30/2011 00555-1117-07 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 6/30/2011 00574-2017-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 00641-0121-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 00641-2341-41 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 38779-0731-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 00641-0121-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 00088-1206-32 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 00088-1208-06 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 00088-1208-69 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 9/30/2013 00088-1208-76 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 7/1/2010 00088-1209-26 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 00006-3941-32 J1453 FOSAPREPITANT INJECTION EMEND 150 MG VIAL 11/15/2010 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00006-3884-32 J1453 FOSAPREPITANT INJECTION EMEND 115 MG VIAL 11/1/2009 7/31/2012 64208-8234-01 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 99/99/9999 64208-8234-02 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 99/99/9999 64208-8234-03 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 99/99/9999 61953-0005-02 J1566 INJECTION, IMMUNE GLOBULIN FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 00944-2655-03 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 G (IGA<1) SOLN 3/1/2010 99/99/9999 00944-2655-04 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 G (IGA<1) SOL 3/1/2010 99/99/9999 00944-0471-75 J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 5 GM VIAL-DILUE 3/1/2010 12/31/2010 00944-0471-80 J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 10 GM VIAL-DILU 3/1/2010 12/31/2010 00944-2620-01 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 0.5 GM VL W-ST 3/1/2010 12/31/2012 00944-2620-02 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 2.5 GM VL W/ST 3/1/2010 5/25/2013 00944-2620-03 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 GM VL W/SET 3/1/2010 4/11/2014 00944-2620-04 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 GM VL W/ST 3/1/2010 6/21/2014 44206-0416-03 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 3 GM VIAL 3/1/2010 6/3/2014 44206-0417-06 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 6 GM VIAL 3/1/2010 99/99/9999 44206-0418-12 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 12 GM VIAL 3/1/2010 99/99/9999 64193-0250-50 J1566 INJECTION, IMMUNE GLOBULIN IVEEGAM EN 5 GM VIAL 3/1/2010 12/31/2010 61953-0005-02 J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 61953-0005-03 J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 11/15/2010 99/99/9999 61953-0003-01 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 61953-0003-02 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 61953-0003-03 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 61953-0003-04 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 61953-0004-01 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 61953-0004-02 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 61953-0004-03 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 61953-0004-04 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 61953-0004-05 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 55390-0250-10 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 9/30/2011 63323-0318-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 63323-0319-04 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 99/99/9999 66758-0035-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 66758-0036-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 99/99/9999 66758-0037-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 12/31/2010 00703-7973-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 1/1/2010 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 63323-0317-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/2010 99/99/9999 00703-7871-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 1/1/2010 8/31/2010 00703-7891-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/2010 12/31/2010 00703-7971-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 10019-0053-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 6/28/2010 60505-0764-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 99/99/9999 00004-0239-09 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 1 MG/ML VIAL 6/1/2009 7/31/2010 00004-0240-09 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 4 MG/4 ML VIAL 6/1/2009 11/30/2011 00004-0242-08 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 0.1 MG/ML VIAL 6/1/2009 3/31/2010 00045-0253-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/2011 00045-0253-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/2011 00045-0254-14 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 100 AMPUL 3/1/2008 5/31/2011 00703-7011-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 00703-7013-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 00703-7021-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 00703-7023-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 55390-0412-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/2011 55390-0412-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/2011 55390-0413-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/2011 55390-0413-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/2011 60505-0702-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 60505-0703-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 63323-0469-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 63323-0469-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 63323-0471-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 63323-0471-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 64011-0243-01 J1725 HYDROXYPROGESTERONE CAPROATE MAKENA 250 MG/ML VIAL 1/1/2012 99/99/9999 00517-0750-01 J1725 HYDROXYPROGESTERONE CAPROATE PROGESTERONE OIL 50 MG/ML VL 1/1/2012 99/99/9999 52544-0931-02 J1750 INJECTION, IRON DEXTRAN INFED 100 MG/2 ML VIAL 1/1/2010 99/99/9999 49230-0534-10 J1750 INJECTION, IRON DEXTRAN VENOFER 100 MG/5 ML VIAL 1/1/2010 99/99/9999 00517-0234-10 J1750 INJECTION, IRON DEXTRAN DEXFERRUM 100 MG/2 ML VIAL 1/1/2010 99/99/9999 10019-0030-12 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 5/15/2009 5/31/2013 00409-2287-21 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML ISECURE SYR 3/1/2008 4/1/2012 00409-2287-22 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2ML ISECURE 3/1/2008 10/1/2011 00409-2287-31 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00409-2287-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 99/99/9999 00409-2288-21 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML ISECURE SYR 3/1/2008 12/31/2012 00409-2288-31 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML CARPUJECT 3/1/2008 99/99/9999 00409-3793-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 00409-3793-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 00409-3795-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 00409-3795-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 00409-3795-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 9/30/2011 00409-3796-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 00409-3796-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 00409-3796-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 7/1/2011 10019-0021-09 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML SYRINGE 3/1/2008 3/31/2010 10019-0022-09 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML SYRINGE 3/1/2008 3/31/2010 10019-0022-32 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC IM 30 MG/ML SYRING 3/1/2008 3/31/2010 10019-0029-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 10/31/2013 10019-0030-03 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 5/31/2013 10019-0030-04 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 8/31/2013 55390-0480-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 55390-0481-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 55390-0481-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 55390-0481-10 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 300 MG/10 ML VIAL 3/1/2008 99/99/9999 63323-0161-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 63323-0162-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 63323-0162-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 64679-0757-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 64679-0757-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 64679-0758-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 64679-0758-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 64679-0758-04 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 64679-0758-05 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 3/31/2010 64679-0758-06 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 00003-0293-05 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KENALOG-40 40 MG/ML VIAL 3/1/2008 99/99/9999 00074-3663-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 11.25 MG 3MO KIT 1/1/2012 99/99/9999 00074-3346-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 22.5 MG 3MO KIT 1/1/2012 99/99/9999 00074-3641-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 3.75 MG KIT 1/1/2012 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 65757-0300-01 J2315 INJECTION, NALTREXONE, DEPOT FORM, 1 MG VIVITROL 380 MG VIAL + DILUENT 7/1/2010 99/99/9999 00078-0340-61 J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 10 MG KIT 11/1/2011 99/99/9999 00078-0341-61 J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 20 MG KIT 11/1/2011 99/99/9999 00078-0342-61 J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 30 MG KIT 11/1/2011 99/99/9999 00641-6080-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 8/29/2012 99/99/9999 10019-0905-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 9/9/2009 9/30/2013 00781-5238-64 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/2009 99/99/9999 00781-5239-80 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 8 MG TABLET 6/1/2009 99/99/9999 00409-4755-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 00409-4755-63 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 00781-3010-95 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 10019-0905-17 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2013 00143-9771-06 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 2/8/2011 99/99/9999 00143-9890-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 00143-9891-05 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 00173-0442-00 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 2 MG/ML VIAL 6/1/2009 99/99/9999 00173-0442-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 4 MG/2 ML VIAL 6/1/2009 3/31/2012 00338-1762-41 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 32 MG/50 ML BAG 6/1/2009 10/31/2012 00409-1120-62 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML SYR 6/1/2009 3/1/2013 00409-4755-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 00409-4755-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 00409-4755-61 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/2010 00409-4755-62 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/2010 00409-4759-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 00409-4760-13 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/2009 9/30/2011 00703-7221-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 6/30/2011 00703-7221-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 12/10/2009 00703-7221-04 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 00703-7226-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 00703-7226-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 00703-7239-39 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/2009 12/31/2012 00781-3057-14 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 8/31/2011 00781-3057-80 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 1/31/2010 10019-0905-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2013 10019-0906-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 7/31/2013

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 10019-0906-04 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/24/2009 12/31/2011 55390-0121-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 55390-0121-10 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 55390-0307-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/2011 55390-0307-10 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 12/31/2010 60505-0744-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 60505-0744-06 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 61703-0244-07 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 61703-0245-22 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/2011 63323-0373-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 63323-0374-20 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 64679-0726-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 64679-0727-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 00781-3010-72 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 68462-0157-13 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/2009 99/99/9999 00781-5257-31 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG TABLET 6/1/2009 1/31/2013 66860-0088-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 2/26/2010 12/31/2010 10019-0905-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 1/1/2010 9/30/2013 00641-6078-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 11/1/2011 99/99/9999 00641-6078-25 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 3/8/2012 99/99/9999 00409-3795-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG KETOROLAC 30 MG/ML VIAL 6/1/2009 99/99/9999 40042-0019-10 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 2/26/2010 12/31/2010 00078-0463-91 J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 30 MG VIAL 3/1/2008 12/31/2010 00078-0464-61 J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 90 MG VIAL 3/1/2008 12/31/2010 00703-4075-19 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIA 3/1/2008 12/31/2010 00703-4075-59 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 12/31/2010 00703-4085-11 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIA 3/1/2008 12/31/2010 00703-4085-51 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 12/31/2010 00781-3147-84 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 2/28/2010 00781-3148-70 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 5/31/2010 15210-0401-11 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 3/31/2010 15210-0402-11 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 3/31/2010 55390-0127-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 12/31/2010 55390-0129-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 12/31/2010 55390-0157-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 12/31/2010

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 55390-0159-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 12/31/2010 55390-0204-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 12/31/2010 55390-0604-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 12/31/2010 61703-0324-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 12/31/2010 61703-0324-39 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 12/31/2010 61703-0325-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 60 MG/10 ML VIAL 3/1/2008 12/31/2010 61703-0326-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 12/31/2010 61703-0356-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 12/31/2010 63323-0734-10 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 12/31/2010 63323-0734-35 J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 3 MG/ML VIA 3/1/2008 12/31/2010 63323-0735-10 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 12/31/2010 63323-0735-35 J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 9 MG/ML VIA 3/1/2008 3/31/2010 54396-0801-01 J2507 PEGLOTICASE INJECTION KRYSTEXXA 8 MG/ML VIAL 1/1/2012 99/99/9999 63323-0300-20 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 8/30/2011 99/99/9999 63323-0320-50 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 4.5 GM VIAL 8/30/2011 99/99/9999 25021-0164-30 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 11/8/2011 99/99/9999 25021-0165-30 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 11/8/2011 99/99/9999 00409-3378-13 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 2/8/2011 99/99/9999 00409-3385-13 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 2/6/2011 99/99/9999 00781-3110-95 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 1/1/2011 99/99/9999 00206-8852-16 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 4/1/2008 99/99/9999 00206-8852-18 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2/0.25 GM ADD-VANTAGE VL 4/1/2008 3/31/2010 00206-8854-16 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GRAM VIAL 4/1/2008 99/99/9999 00206-8854-18 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3/0.375 GM ADD-VANTAGE 4/1/2008 6/30/2008 00206-8855-16 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GRAM VIAL 4/1/2008 99/99/9999 00206-8855-18 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4/0.5 GM ADD-VANTAGE VL 4/1/2008 6/30/2008 00206-8859-10 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 40.5 GRAM BULK VIAL 4/1/2008 99/99/9999 00206-8860-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GM/50 ML GALAXY BAG 4/1/2008 99/99/9999 00206-8861-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GM/50 ML GALAXY 4/1/2008 99/99/9999 00206-8862-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 4/1/2008 99/99/9999 00206-2413-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 8/30/2011 99/99/9999 00206-2404-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 8/30/2011 99/99/9999 00206-2405-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GRAM VIAL 7/19/2010 99/99/9999 00206-8854-08 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GRAM VIAL 5/29/2008 99/99/9999 00143-9868-22 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 12/30/2008 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00143-9869-22 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 12/30/2008 99/99/9999 60977-0001-43 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 9/2/2008 1/31/2014 60977-0002-43 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 5/29/2008 4/30/2014 39822-5500-05 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 8/16/2012 99/99/9999 00641-1496-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/2008 99/99/9999 00008-0063-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 3/1/2008 3/31/2010 00008-0746-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 3/1/2008 3/31/2010 00409-2312-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML SYRINGE 3/1/2008 12/31/2012 00591-3157-83 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/2008 3/31/2008 00591-3158-83 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/2008 3/31/2008 00641-0928-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 99/99/9999 00641-0928-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 99/99/9999 00641-0929-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/2/2008 99/99/9999 00641-0929-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/2008 99/99/9999 00641-0948-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/2008 99/99/9999 00641-0948-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/2008 99/99/9999 00641-0949-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/2008 99/99/9999 00641-0955-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 99/99/9999 00641-0956-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/2008 99/99/9999 00641-1495-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/2008 99/99/9999 00641-1495-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/2008 99/99/9999 00641-1496-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/2008 99/99/9999 00703-2191-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 99/99/9999 00703-2201-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/2008 99/99/9999 10019-0097-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 6/30/2013 10019-0097-44 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 6/30/2013 51552-0147-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/2011 51552-0147-02 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/2011 51552-0147-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/2011 51552-0147-05 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/2011 60977-0001-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 3/1/2008 1/31/2014 60977-0001-03 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 3/1/2008 4/30/2013 60977-0001-44 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 3/1/2008 4/30/2013 60977-0002-02 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 3/1/2008 4/30/2014 60977-0002-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML VIAL 3/1/2008 12/31/2012

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 60977-0002-44 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML VIAL 3/1/2008 12/31/2012 00703-2191-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 99/99/9999 00703-2201-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/2008 99/99/9999 00641-0956-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/2/2008 99/99/9999 00641-0955-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/2/2008 99/99/9999 00409-1253-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG DEMEROL 50 MG/ML AMPUL 4/1/2008 99/99/9999 50242-0082-01 J2778 Ranibizumab injection LUCENTIS 0.3 MG VIAL 10/1/2012 99/99/9999 50242-0080-01 J2778 Ranibizumab injection LUCENTIS 0.5 MG VIAL 9/1/2009 99/99/9999 00469-6501-89 J2785 REGADENOSON INJECTION LEXISCAN INJECTION 9/1/2009 99/99/9999 55513-0221-01 J2796 INJECTION, ROMIPLOSTIM, 10 MCG NPLATE 250 MCG VIAL 1/1/2010 99/99/9999 55513-0222-01 J2796 INJECTION, ROMIPLOSTIM, 10 MCG NPLATE 500 MCG VIAL 1/1/2010 99/99/9999 00591-0149-87 J2916 FERRLECIT SOD FER GLUC CPLX 62.5 MG/5 ML 8/16/2012 99/99/9999 52544-0149-87 J2916 FERRLECIT NULECIT 62.5 MG/5 ML VIAL 5/25/2011 99/99/9999 00024-2791-50 J2916 FERRLECIT FERRLECIT 62.5 MG/5 ML AMPUL 5/7/2010 10/31/2014 00024-2792-10 J2916 FERRLECIT FERRLECIT 62.5 MG/5 ML VIAL 7/1/2011 99/99/9999 52544-0922-26 J2916 FERRLECIT FERRLECIT 62.5 MG/5 ML AMPUL 1/1/2010 10/31/2011 00406-1130-52 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/2011 00409-1276-32 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML SYRINGE 3/1/2008 99/99/9999 00409-9093-35 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 99/99/9999 00409-9093-36 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 9/1/2011 00409-9093-38 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 99/99/9999 00409-9094-22 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 99/99/9999 00409-9094-25 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 99/99/9999 00409-9094-28 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 99/99/9999 00409-9094-31 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 99/99/9999 00409-9094-61 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 99/99/9999 10019-0033-72 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 5/31/2015 10019-0034-73 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 6/28/2010 10019-0035-74 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 99/99/9999 10019-0036-82 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 1/28/2009 10019-0037-83 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 5/31/2014 10019-0038-67 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 4/30/2015 11098-0030-02 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/2008 12/31/2011 11098-0030-05 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/2008 7/31/2011 11098-0030-10 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/2008 3/25/2010

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 11098-0030-20 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/2008 9/30/2011 51552-0687-01 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/2011 51552-0687-09 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/2011 00409-9093-32 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 99/99/9999 38779-1756-03 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/2011 38779-1756-04 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 12/31/2012 10019-0038-39 J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 9/2/2008 4/30/2015 00065-0543-01 J3300 TRIAMCINOLONE A INJ PRS-FREE TRIESENCE 40 MG/ML VIAL 3/1/2013 99/99/9999 00003-0293-05 J3300 TRIAMCINOLONE A INJ PRS-FREE KENALOG-40 40 MG/ML VIAL 3/1/2013 99/99/9999 00003-0494-20 J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG-10 10 MG/ML VIAL 1/1/2012 99/99/9999 00003-0293-05 J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG-40 40 MG/ML VIAL 1/1/2012 99/99/9999 00003-0293-20 J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG-40 40 MG/ML VIAL 1/1/2012 99/99/9999 00003-0293-28 J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG-40 40 MG/ML VIAL 1/1/2012 99/99/9999 00781-3085-71 J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG ARISTOSPAN 20 MG/ML VIAL 1/1/2012 99/99/9999 00781-3085-75 J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG ARISTOSPAN 20 MG/ML VIAL 1/1/2012 99/99/9999 00338-3551-48 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN-D5W 500 MG/100 ML 6/1/2009 99/99/9999 00338-3552-48 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 1G/200 ML BAG 6/1/2009 99/99/9999 00409-4332-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 6/1/2009 99/99/9999 00409-4332-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 6/1/2009 99/99/9999 00409-6509-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 6/1/2009 99/99/9999 00409-6509-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 6/1/2009 99/99/9999 00409-6533-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/2009 99/99/9999 00409-6533-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/2009 99/99/9999 00409-6533-61 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/2009 9/30/2011 00409-6534-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG A-V VIAL 6/1/2009 99/99/9999 00409-6534-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG A-V VIAL 6/1/2009 99/99/9999 00409-6535-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM ADD-VAN VIAL 6/1/2009 99/99/9999 00409-6535-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM ADD-VAN VIAL 6/1/2009 99/99/9999 63323-0221-10 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 6/1/2009 99/99/9999 63323-0284-20 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/2009 99/99/9999 63323-0295-61 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 6/1/2009 99/99/9999 63323-0314-61 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 10 GM VIAL 6/1/2009 99/99/9999 50242-0087-01 J3490 UNCLASSIFIED DRUGS KADCYLA 160 MG VIAL 4/1/2013 12/31/2013 50242-0088-01 J3490 UNCLASSIFIED DRUGS KADCYLA 100 MG VIAL 4/1/2013 12/31/2013 50419-0422-01 J3490 UNCLASSIFIED DRUGS SKYLA SYSTEM 1/14/2013 12/31/2013

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00023-3348-07 J3490 UNCLASSIFIED DRUGS OZURDEX 0.7 MG IMPLANT 11/9/2009 1/31/2013 00065-0543-01 J3490 UNCLASSIFIED DRUGS TRIESENCE 40 MG/ML VIAL 6/1/2008 1/31/2013 63323-0270-25 J3490 UNCLASSIFIED DRUGS PROPOFOL 10 MG/ML VIAL 8/30/2011 12/27/2013 00409-1559-30 J3490 UNCLASSIFIED DRUGS MARCAINE 0.25% VIAL 6/1/2008 99/99/9999 50242-0145-01 J3590 UNCLASSIFIED BIOLOGICS PERJETA 420 MG/14 ML VIAL 8/29/2012 12/31/2013 63833-0825-02 J3590 UNCLASSIFIED BIOLOGICS BERINERT 500 UNIT KIT 2/26/2010 1/31/2013 00338-6304-02 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00264-1800-32 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00264-4002-55 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 11/30/2013 00264-7800-20 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SALINE 0.9% SOLN-EXCEL CONT 3/1/2008 99/99/9999 00338-0044-02 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN 3/1/2008 10/31/2009 00338-0049-01 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00338-0049-02 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00338-0049-18 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00338-0049-38 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00338-0049-41 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00338-0049-48 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00338-0553-18 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN. 3/1/2008 99/99/9999 00409-1583-01 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 9/30/2011 00409-1583-02 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 9/30/2011 00409-1584-11 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 12/1/2011 00409-7101-02 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN 3/1/2008 99/99/9999 00409-7101-67 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN 3/1/2008 99/99/9999 00409-7983-02 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00409-7983-53 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00409-7983-61 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00409-7984-23 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 00409-7984-37 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 99/99/9999 63323-0186-00 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% VIAL 3/1/2008 99/99/9999 00409-1966-07 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC BACTERIOSTATIC SALINE VIAL 3/1/2008 99/99/9999 00409-7983-25 J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 8/3/2009 99/99/9999 00053-7656-01 J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 250 UNIT KIT 3/1/2008 3/31/2010 00053-7656-02 J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 500AHFU KIT 3/1/2008 3/31/2010 00053-7656-04 J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 1,000 UNITS KIT 3/1/2008 11/5/2012 00053-7656-05 J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 1,500 UNITS KIT 3/1/2008 10/28/2012

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00944-1301-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 220-400 UNITS VIAL 3/1/2008 12/31/2010 00944-1302-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 401-800 UNITS VIAL 3/1/2008 12/31/2010 00944-1303-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 801-1,700 UNITS VIAL 3/1/2008 12/31/2010 00944-1304-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 1,701-2,000 UNITS VL 3/1/2008 12/31/2010 00944-2935-01 J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 220-400 UNITS VIAL 3/1/2008 12/31/2010 00944-2935-02 J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 401-800 UNITS VIAL 3/1/2008 8/27/2010 00944-2935-03 J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 801-1,700 UNITS VIAL 3/1/2008 12/31/2010 00944-2935-04 J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 1,701-2,000 UNITS VL 3/1/2008 10/8/2010 00026-0372-20 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNIT VIAL 3/1/2008 12/31/2010 00026-0372-30 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 500 UNIT VIAL 3/1/2008 12/31/2010 00026-0372-50 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 3/1/2008 12/31/2010 00026-0379-20 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNITS VIAL 3/1/2008 12/31/2010 00026-0379-30 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 500 UNITS VIAL 3/1/2008 12/31/2010 00026-0379-50 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 3/1/2008 12/31/2010 00026-3786-60 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 2,000 UNIT VIAL 3/1/2008 99/99/9999 00026-3796-60 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 2,000 UNIT VIAL 3/1/2008 99/99/9999 00053-8130-01 J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 250 UNIT VIAL 3/1/2008 12/15/2011 00053-8130-02 J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 500 UNIT VIAL 3/1/2008 2/17/2012 00053-8130-04 J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 1,000 UNIT VIAL 3/1/2008 2/24/2012 00944-2831-10 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 220-400 UNIT VIAL 3/1/2008 11/2/2012 00944-2832-10 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 401-800 UNIT VIAL 3/1/2008 4/26/2013 00944-2833-10 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 801-1,240 UNIT VL 3/1/2008 4/26/2013 00944-2938-01 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 220-400 UNIT VL 3/1/2008 12/31/2010 00944-2938-02 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 401-800 UNIT VL 3/1/2008 12/31/2010 00944-2938-03 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 801-1,240 UNITS VL 3/1/2008 12/31/2010 00944-2940-01 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 250 UNITS VIAL 3/1/2008 2/4/2010 00944-2940-02 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 500 UNITS VIAL 3/1/2008 2/4/2010 00944-2940-03 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,000 UNITS VIAL 3/1/2008 2/4/2010 00944-2940-04 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,500 UNITS VIAL 3/1/2008 2/4/2010 00944-2940-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,800-2,200 UNITS VIAL 3/1/2008 2/4/2010 00944-2941-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 200-400 UNITS VIAL 3/1/2008 99/99/9999 00944-2942-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 401-800 UNITS VIAL 3/1/2008 99/99/9999 00944-2943-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 801-1,200 UNITS VIAL 3/1/2008 99/99/9999 00944-2944-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,201-1,800 UNITS VIAL 3/1/2008 99/99/9999 00944-2945-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,801-2,400 UNITS VIAL 3/1/2008 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00944-2946-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 2,401-3,600 UNITS VIAL 3/1/2008 99/99/9999 58394-0005-02 J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 1,000 UNITS VIAL 3/1/2008 3/31/2010 58394-0006-02 J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 500 UNITS VIAL 3/1/2008 3/31/2010 58394-0007-02 J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 250 UNITS VIAL 3/1/2008 3/31/2010 58394-0011-02 J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 2,000 UNITS VIAL 3/1/2008 3/31/2010 00026-3782-20 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNIT VIAL 12/30/2008 99/99/9999 00026-3785-50 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 5/15/2009 99/99/9999 50419-0422-01 J7301 SKYLA 13.5MG SKYLA SYSTEM 1/1/2014 99/99/9999 00023-3348-07 J7312 DEXAMETHASONE INTRA IMPLANT OZURDEX 0.7 MG IMPLANT 2/1/2013 99/99/9999 00378-6989-66 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 11/9/2009 12/31/2009 Y 00172-6407-44 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00172-6407-49 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00472-0751-23 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00472-0751-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00472-0751-60 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00472-0753-23 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00472-0753-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00472-0753-60 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00487-9801-01 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00487-9801-02 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00487-9801-25 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00487-9801-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 00487-9801-60 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 16252-0098-22 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 16252-0098-33 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 16252-0098-66 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 49502-0685-26 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 49502-0685-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 49502-0685-61 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 51552-0393-01 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/2008 12/31/2009 Y 51552-0393-02 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/2008 12/31/2009 Y 51552-0393-04 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/2008 12/31/2009 Y 51552-0393-05 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/2008 12/31/2009 Y 60505-0806-01 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 66794-0002-25 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 6/30/2009 Y

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 66794-0002-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 5/31/2009 Y 66794-0002-60 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 6/30/2009 Y 49502-0685-62 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 12/31/2009 Y 49502-0685-31 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 12/30/2008 12/31/2009 Y 00078-0414-20 J8561 ORAL EVEROLIMUS ZORTRESS 0.5 MG TABLET 1/1/2012 12/31/2012 00078-0415-20 J8561 ORAL EVEROLIMUS ZORTRESS 0.75 MG TABLET 1/1/2012 12/31/2012 00078-0417-20 J8561 ORAL EVEROLIMUS ZORTRESS 0.25 MG TABLET 1/1/2012 12/31/2012 00078-0567-51 J8561 ORAL EVEROLIMUS AFINITOR 10 MG TABLET 1/1/2012 12/31/2012 00078-0594-51 J8561 ORAL EVEROLIMUS AFINITOR 2.5 MG TABLET 1/1/2012 12/31/2012 00078-0566-51 J8561 ORAL EVEROLIMUS AFINITOR 5 MG TABLET 1/1/2012 12/31/2012 00703-5040-01 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 3/1/2008 99/99/9999 00703-5043-03 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 3/1/2008 99/99/9999 00703-5046-01 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 3/1/2008 99/99/9999 10019-0921-02 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG VIAL 3/1/2008 6/30/2008 55390-0231-10 J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 10 MG VIAL 3/1/2008 99/99/9999 55390-0232-10 J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 20 MG VIAL 3/1/2008 99/99/9999 55390-0233-01 J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 50 MG VIAL 3/1/2008 99/99/9999 55390-0235-10 J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 2 MG/ML VIAL 3/1/2008 11/30/2012 55390-0236-10 J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 2 MG/ML VIAL 3/1/2008 99/99/9999 55390-0237-01 J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 2 MG/ML VIAL 3/1/2008 99/99/9999 55390-0238-01 J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 200 MG/100 ML VIAL 3/1/2008 99/99/9999 55390-0241-10 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG VIAL 3/1/2008 6/30/2014 55390-0243-01 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG VIAL 3/1/2008 5/31/2014 55390-0245-10 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 3/1/2008 9/30/2012 55390-0246-10 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 20 MG/10 ML VIAL 3/1/2008 1/31/2013 55390-0247-01 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 3/1/2008 1/31/2013 55390-0248-01 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 3/1/2008 11/30/2012 63323-0101-61 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 3/1/2008 99/99/9999 63323-0883-05 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 3/1/2008 99/99/9999 63323-0883-10 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 20 MG/10 ML VIAL 3/1/2008 99/99/9999 63323-0883-30 J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 3/1/2008 99/99/9999 63323-0137-20 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 5/15/2009 99/99/9999 00015-3010-20 J9040 BLEOMYCIN SULFATE, 15 UNITS BLENOXANE 15 UNITS VIAL 3/1/2008 1/31/2009 00015-3063-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLENOXANE 30 UNITS VIAL 3/1/2008 2/28/2009 00703-3154-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 3/1/2008 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00703-3154-91 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNITS VIA 3/1/2008 3/31/2010 00703-3155-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 3/1/2008 99/99/9999 00703-3155-91 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNITS VIA 3/1/2008 12/31/2010 55390-0005-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 3/1/2008 9/30/2011 55390-0006-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 3/1/2008 9/30/2011 61703-0323-22 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 3/1/2008 99/99/9999 61703-0332-18 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 3/1/2008 99/99/9999 00024-5824-11 J9043 CABAZITAXEL INJECTION JEVTANA 60 MG/1.5 ML KIT 1/1/2012 99/99/9999 66758-0047-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 12/30/2008 99/99/9999 66758-0047-02 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 12/30/2008 99/99/9999 66758-0047-03 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 12/30/2008 99/99/9999 66758-0047-04 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 5/7/2010 99/99/9999 00015-3213-30 J9045 CARBOPLATIN, 50 MG PARAPLATIN 50 MG VIAL 3/1/2008 3/31/2008 00015-3214-30 J9045 CARBOPLATIN, 50 MG PARAPLATIN 150 MG VIAL 3/1/2008 5/14/2008 00015-3215-30 J9045 CARBOPLATIN, 50 MG PARAPLATIN 450 MG VIAL 3/1/2008 4/30/2008 00409-1129-10 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 3/31/2010 00409-1129-11 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/31/2010 00409-1129-12 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 3/31/2010 00591-3336-26 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 8/31/2009 00591-3337-12 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/30/2009 00591-3338-89 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 4/30/2009 00591-3454-60 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 3/31/2009 00703-3249-11 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 99/99/9999 00703-3264-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 3/31/2008 00703-3266-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 5/31/2008 00703-3268-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 4/30/2008 00703-3274-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 5/31/2009 00703-3276-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 2/28/2010 00703-3278-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 8/31/2010 00703-4244-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 99/99/9999 00703-4246-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 99/99/9999 00703-4248-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 99/99/9999 15210-0061-12 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 3/31/2010 15210-0063-12 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/31/2010 15210-0066-12 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 3/31/2010

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 15210-0067-12 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 3/31/2010 50111-0965-76 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 10/31/2010 50111-0966-76 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 10/31/2010 50111-0967-76 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 3/31/2010 55390-0150-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 9/30/2011 55390-0151-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 9/30/2011 55390-0152-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 9/30/2011 55390-0153-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 9/30/2011 55390-0154-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 9/30/2011 55390-0155-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 9/30/2011 55390-0156-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 9/30/2011 55390-0220-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 3/31/2010 55390-0221-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/31/2010 55390-0222-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 3/31/2010 61703-0339-18 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 99/99/9999 61703-0339-22 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 99/99/9999 61703-0339-50 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 99/99/9999 61703-0339-56 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 99/99/9999 61703-0360-18 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 99/99/9999 61703-0360-22 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 99/99/9999 61703-0360-50 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 99/99/9999 63323-0166-10 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 3/31/2011 63323-0167-21 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 99/99/9999 63323-0168-00 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 3/31/2010 63323-0172-45 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 99/99/9999 63323-0172-60 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 99/99/9999 00069-0081-01 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 100 MG/100 ML VIAL 8/29/2012 99/99/9999 00703-5747-11 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 50 MG/50 ML VIAL 3/1/2008 99/99/9999 00703-5748-11 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 100 MG/100 ML VIAL 3/1/2008 99/99/9999 55390-0099-01 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/2011 55390-0112-50 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/2011 55390-0112-99 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/2011 55390-0187-01 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/2011 55390-0414-50 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/2011 55390-0414-99 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/2011

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 63323-0103-51 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 50 MG/50 ML VIAL 3/1/2008 99/99/9999 63323-0103-64 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 200 MG/200 ML VIAL 3/1/2008 99/99/9999 63323-0103-65 J9060 CISPLATIN 10 MG INJECTION CISPLATIN 100 MG/100 ML VIAL 3/1/2008 99/99/9999 00703-5747-11 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 50 MG/50 ML VIAL 6/1/2009 12/31/2010 00703-5748-11 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 100 MG/100 ML VIAL 6/1/2009 12/31/2010 55390-0099-01 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/2009 12/31/2010 55390-0112-50 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/2009 12/31/2010 55390-0112-99 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/2009 12/31/2010 55390-0187-01 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/2009 12/31/2010 55390-0414-50 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/2009 12/31/2010 55390-0414-99 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/2009 12/31/2010 63323-0103-51 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 50 MG/50 ML VIAL 6/1/2009 12/31/2010 63323-0103-64 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 200 MG/200 ML VIAL 6/1/2009 12/31/2010 63323-0103-65 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 100 MG/100 ML VIAL 6/1/2009 12/31/2010 66758-0050-02 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/8 ML VIAL 8/15/2011 99/99/9999 66758-0050-03 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 160 MG/16 ML VIAL 8/15/2011 99/99/9999 00409-0201-02 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/2 ML VIAL 5/25/2011 99/99/9999 00409-0201-10 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/8 ML VIAL 5/25/2011 99/99/9999 00409-0201-20 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 160 MG/16 ML VIAL 3/17/2011 99/99/9999 00075-8003-01 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 20 MG/ML VIAL 10/11/2010 99/99/9999 00075-8004-04 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 80 MG/4 ML VIAL 10/11/2010 99/99/9999 00955-1020-01 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/ML VIAL 3/14/2011 99/99/9999 00955-1021-04 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/4 ML VIAL 3/14/2011 99/99/9999 00075-8001-20 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 20 MG/0.5 ML VIAL 1/1/2010 5/31/2012 16729-0120-49 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/0.5 ML VIAL 7/11/2011 99/99/9999 16729-0228-50 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/2 ML VIAL 7/11/2011 99/99/9999 00075-8001-80 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 80 MG/2 ML VIAL 1/1/2010 6/30/2013 61703-0359-01 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 99/99/9999 61703-0359-02 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 99/99/9999 61703-0359-91 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 150 MG/75 ML VIAL 6/1/2009 9/30/2011 61703-0359-92 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 10 MG/5 ML VIAL 6/1/2009 9/30/2011 10518-0104-10 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 9/30/2011 10518-0104-11 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 9/30/2011 63323-0151-00 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 1/1/2010 99/99/9999 63323-0151-05 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 10 MG/5 ML VIAL 1/1/2010 3/31/2011

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 63323-0151-25 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 1/1/2010 99/99/9999 63323-0151-75 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 150 MG/75 ML VIAL 1/1/2010 3/31/2011 00009-5091-01 J9178 EPIRUBICIN, INJECTION ELLENCE 2 MG/ML VIAL 6/1/2009 99/99/9999 00009-5093-01 J9178 EPIRUBICIN, INJECTION ELLENCE 2 MG/ML VIAL 6/1/2009 99/99/9999 00703-3067-11 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 99/99/9999 00703-3069-11 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 99/99/9999 55390-0207-01 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 9/30/2011 55390-0208-01 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 9/30/2011 59762-5091-01 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 2/28/2011 59762-5093-01 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 10/31/2010 61703-0347-35 J9178 EPIRUBICIN, INJECTION EPIRUBICIN HCL 50 MG VIAL 6/1/2009 99/99/9999 61703-0359-59 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 99/99/9999 61703-0359-93 J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 99/99/9999 62856-0389-01 J9179 ERIBULIN MESYLATE INJECTION HALAVEN 1 MG/2 ML VIAL 1/1/2012 99/99/9999 00187-3953-64 J9190 FLUOROURACIL, 500 MG FLUOROURACIL 50 MG/ML VIAL 5/1/2009 3/31/2010 00703-3015-13 J9190 FLUOROURACIL, 500 MG ADRUCIL 50 MG/ML VIAL 5/1/2009 99/99/9999 00703-3018-12 J9190 FLUOROURACIL, 500 MG ADRUCIL 50 MG/ML VIAL 5/1/2009 99/99/9999 00703-3019-12 J9190 FLUOROURACIL, 500 MG ADRUCIL 5 GRAM/100 ML VIAL 5/1/2009 99/99/9999 51552-0733-01 J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/2011 51552-0733-02 J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/2011 51552-0733-04 J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/2011 51552-0733-05 J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/2011 63323-0117-10 J9190 FLUOROURACIL, 500 MG FLUOROURACIL 500 MG/10 ML VIAL 5/1/2009 99/99/9999 63323-0117-20 J9190 FLUOROURACIL, 500 MG FLUOROURACIL 1,000 MG/20 ML VL 5/1/2009 99/99/9999 63323-0117-51 J9190 FLUOROURACIL, 500 MG FLUOROURACIL 2,500 MG/50 ML VL 5/1/2009 99/99/9999 63323-0117-61 J9190 FLUOROURACIL, 500 MG FLUOROURACIL 5,000 MG/100 ML 5/1/2009 99/99/9999 10139-0063-50 J9190 FLUOROURACIL, 500 MG FLUOROURACIL 2,500 MG/50 ML VL 5/15/2009 99/99/9999 66758-0048-01 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 5/7/2010 99/99/9999 00703-4432-11 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 99/99/9999 00703-4434-11 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 99/99/9999 00703-4434-91 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 3/31/2012 00781-3066-72 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 6/30/2011 00781-3066-75 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 10/31/2011 10518-0103-10 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 3/31/2011 10518-0103-11 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 7/30/2010

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 61703-0349-09 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 99/99/9999 61703-0349-16 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 99/99/9999 61703-0349-36 J9206 IRINOTECAN IRINOTECAN HCL 500 MG/25 ML VL 6/1/2009 99/99/9999 61703-0349-61 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 9/30/2011 61703-0349-62 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 9/30/2011 63323-0193-02 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 99/99/9999 63323-0193-05 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 99/99/9999 00591-3189-02 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML INJ 6/1/2009 12/31/2009 00591-3189-26 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML INJ 6/1/2009 12/30/2009 00009-7529-01 J9206 IRINOTECAN CAMPTOSAR 20 MG/ML VIAL 6/1/2009 9/1/2013 00009-7529-02 J9206 IRINOTECAN CAMPTOSAR 20 MG/ML VIAL 6/1/2009 6/1/2013 00009-7529-03 J9206 IRINOTECAN CAMPTOSAR 100 MG/5 ML VIAL 11/29/2010 99/99/9999 10019-0934-01 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 11/30/2010 10019-0934-02 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 1/30/2011 10019-0934-17 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 1/30/2010 10019-0934-79 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 1/30/2011 00009-7529-04 J9206 IRINOTECAN CAMPTOSAR 40 MG/2 ML VIAL 2/28/2011 99/99/9999 59762-7529-01 J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 2/1/2011 59762-7529-02 J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 1/1/2013 00015-1910-12 J9207 IXABEPILONE INJECTION IXEMPRA 15 MG KIT 4/1/2013 99/99/9999 00015-1911-13 J9207 IXABEPILONE INJECTION IXEMPRA 45 MG KIT 4/1/2013 99/99/9999 00074-3473-03 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 45 MG 6MO KIT 8/30/2011 99/99/9999 00024-0222-05 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 22.5 MG SYRINGE 3/1/2008 99/99/9999 00024-0605-45 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 45 MG SYRINGE 3/1/2008 99/99/9999 00024-0610-30 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 30 MG SYRINGE 3/1/2008 99/99/9999 00024-0793-75 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 7.5 MG SYRINGE 3/1/2008 99/99/9999 00074-3683-03 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-4 MONTH KIT 4/17/2009 99/99/9999 00300-2108-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 7.5 MG KIT 3/1/2008 12/31/2010 00300-2282-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 11.25 MG KIT 3/1/2008 8/1/2011 00300-2440-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 15 MG KIT 3/1/2008 11/1/2010 00300-3346-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 22.5 MG 3MO KIT 3/1/2008 7/1/2011 00300-3642-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 7.5 MG KIT 3/1/2008 8/1/2011 00300-3663-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 11.25 MG 3MO KIT 3/1/2008 9/30/2011 00300-3683-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-4 MONTH KIT 3/1/2008 7/1/2011 00300-3612-24 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON 1 MG/0.2 ML VIAL 3/1/2008 11/1/2009

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 00074-3346-03 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 22.5 MG 3MO KIT 9/9/2009 99/99/9999 00300-3612-28 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON 2-WK 1 MG/0.2 ML KIT 3/1/2008 1/1/2009 00182-3154-99 J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 1 MG/0.2 ML KIT 3/1/2008 3/31/2010 00185-7400-85 J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KT 3/1/2008 12/31/2012 00300-3612-24 J9218 LEUPROLIDE ACETATE, PER 1 MG LUPRON 1 MG/0.2 ML VIAL 3/1/2008 11/1/2009 00703-4014-18 J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KIT 3/1/2008 99/99/9999 00703-4014-19 J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 1 MG/0.2 ML VIAL 3/1/2008 3/31/2010 49884-0368-26 J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KT 3/1/2008 3/11/2010 00074-3663-03 J9218 LEUPROLIDE ACETATE, PER 1 MG LUPRON DEPOT 11.25 MG 3MO KIT 5/25/2011 99/99/9999 00300-3612-28 J9218 LEUPROLIDE ACETATE, PER 1 MG LUPRON 2-WK 1 MG/0.2 ML KIT 3/1/2008 1/1/2009 00003-2327-11 J9228 IPILIMUMAB INJECTION YERVOY 50 MG/10 ML VIAL 1/1/2012 99/99/9999 00003-2328-22 J9228 IPILIMUMAB INJECTION YERVOY 200 MG/40 ML VIAL 1/1/2012 99/99/9999 00703-4766-01 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 12/31/2008 99/99/9999 00703-4767-01 J9265 PACLITAXEL 30 MG PACLITAXEL 150 MG/25 ML VIAL 12/30/2008 99/99/9999 00555-1984-14 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/2/2008 12/31/2009 00555-1985-14 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/2/2008 12/31/2009 10518-0102-07 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 5/29/2008 7/6/2009 66758-0043-01 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 5/29/2008 99/99/9999 66758-0043-02 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 5/29/2008 99/99/9999 66758-0043-03 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 5/29/2008 99/99/9999 00015-3475-30 J9265 PACLITAXEL 30 MG TAXOL 30 MG/5 ML VIAL 3/1/2008 6/30/2010 00015-3476-30 J9265 PACLITAXEL 30 MG TAXOL 100 MG/16.7 ML VIAL 3/1/2008 7/31/2010 00015-3479-11 J9265 PACLITAXEL 30 MG TAXOL 300 MG/50 ML VIAL 3/1/2008 7/31/2010 00172-3753-77 J9265 PACLITAXEL 30 MG ONXOL 300 MG/50 ML VIAL 3/1/2008 6/30/2010 00172-3753-96 J9265 PACLITAXEL 30 MG ONXOL 300 MG/50 ML VIAL 3/1/2008 8/31/2008 00172-3754-73 J9265 PACLITAXEL 30 MG ONXOL 30 MG/5 ML VIAL 3/1/2008 7/31/2010 00172-3754-94 J9265 PACLITAXEL 30 MG ONXOL 30 MG/5 ML VIAL 3/1/2008 3/31/2010 00172-3756-75 J9265 PACLITAXEL 30 MG ONXOL 150 MG/25 ML VIAL 3/1/2008 5/31/2009 00172-3756-95 J9265 PACLITAXEL 30 MG ONXOL 150 MG/25 ML VIAL 3/1/2008 4/11/2008 10518-0102-08 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 11/30/2009 10518-0102-09 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 3/31/2010 55390-0114-05 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/2008 99/99/9999 55390-0114-20 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 99/99/9999 55390-0114-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 99/99/9999 55390-0304-05 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/2008 11/30/2012

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 55390-0304-20 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 4/30/2013 55390-0304-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 4/30/2013 55390-0314-05 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/2008 3/31/2012 55390-0314-20 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 6/30/2012 55390-0314-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 12/31/2012 55390-0514-05 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/2008 10/31/2009 55390-0514-20 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 12/31/2009 55390-0514-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 12/31/2009 61703-0342-09 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/2008 99/99/9999 61703-0342-22 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 99/99/9999 61703-0342-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 99/99/9999 68817-0134-50 J9265 PACLITAXEL 30 MG ABRAXANE 100 MG VIAL 3/1/2008 99/99/9999 63323-0763-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 11/9/2009 99/99/9999 00703-4768-01 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 11/9/2009 99/99/9999 00703-4680-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 99/99/9999 00703-4680-91 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 3/31/2010 00703-4685-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/2009 99/99/9999 00703-4686-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/2009 99/99/9999 15210-0403-35 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/2009 3/31/2010 15210-0403-36 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 3/31/2010 15210-0403-37 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/2009 3/31/2010 44087-1520-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG NOVANTRONE 2 MG/ML VIAL 6/1/2009 11/30/2013 55390-0083-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/2009 9/30/2011 55390-0084-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 9/30/2011 55390-0085-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/2009 9/30/2011 61703-0343-18 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/2009 99/99/9999 61703-0343-65 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 99/99/9999 61703-0343-66 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/2009 99/99/9999 63323-0132-10 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/2009 99/99/9999 63323-0132-12 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 99/99/9999 63323-0132-15 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/2009 99/99/9999 50242-0145-01 J9306 INJECTION, PERTUZUMAB, 1 MG PERJETA 420 MG/14 ML VIAL 1/1/2014 99/99/9999 48818-0001-02 J9307 PRALATREXATE INJECTION FOLOTYN 40 MG/2 ML VIAL 4/1/2012 99/99/9999 46026-0983-01 J9315 ROMIDEPSIN INJECTION ISTODAX 10 MG VIAL 8/26/2012 99/99/9999 59572-0983-01 J9315 ROMIDEPSIN INJECTION ISTODAX 10 MG VIAL 1/1/2012 99/99/9999

Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 25021-0206-06 J9351 TOPOTECAN INJECTION TOPOTECAN HCL 4 MG VIAL 2/8/2011 99/99/9999 00007-4201-05 J9351 TOPOTECAN INJECTION HYCAMTIN 4 MG VIAL 1/1/2011 9/30/2012 50242-0087-01 J9354 INJ, ADO-TRASTUZUMAB EMT 1MG KADCYLA 160 MG VIAL 1/1/2014 99/99/9999 50242-0088-01 J9354 INJ, ADO-TRASTUZUMAB EMT 1MG KADCYLA 100 MG VIAL 1/1/2014 99/99/9999 64370-0210-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 12/30/2008 6/1/2014 64370-0250-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 12/30/2008 6/1/2014 64370-3086-01 J9390 VINORELBINE TARTRATE, PER 10 MG NAVELBINE 10 MG/ML VIAL 12/30/2008 6/1/2010 64370-3086-02 J9390 VINORELBINE TARTRATE, PER 10 MG NAVELBINE 50 MG/5 ML VIAL 12/30/2008 6/1/2010 66758-0045-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 5/29/2008 99/99/9999 66758-0045-02 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 5/29/2008 99/99/9999 00173-0656-44 J9390 VINORELBINE TARTRATE, PER 10 MG NAVELBINE 10 MG/ML VIAL 3/1/2008 3/31/2008 00703-4182-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 99/99/9999 00703-4182-81 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 3/31/2011 00703-4182-91 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 5/31/2012 00703-4183-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 99/99/9999 00703-4183-81 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 3/31/2011 00703-4183-91 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 12/31/2012 55390-0069-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 99/99/9999 55390-0070-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 99/99/9999 55390-0267-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 12/31/2011 61703-0341-06 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 99/99/9999 61703-0341-09 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 99/99/9999 63323-0148-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 99/99/9999 63323-0148-05 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 99/99/9999 55390-0268-01 J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 12/31/2011 00015-1910-12 J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC IXEMPRA 15 MG KIT 3/1/2008 3/31/2013 00015-1911-13 J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC IXEMPRA 45 MG KIT 3/1/2008 3/31/2013 49401-0101-01 Q2044 BELIMUMAB INJECTION BENLYSTA 120 MG VIAL 7/1/2011 99/99/9999 49401-0102-01 Q2044 BELIMUMAB INJECTION BENLYSTA 400 MG VIAL 7/1/2011 99/99/9999 60574-4114-01 90378 RSV MAB IM 50MG SYNAGIS 50 MG/0.5 ML VIAL 3/1/2008 99/99/9999 60574-4113-01 90378 RSV MAB IM 50MG SYNAGIS 100 MG/1 ML VIAL 3/1/2008 99/99/9999

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