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INJECTABLE MEDICATION HCPCS/DOFR RUG NAMEABELCETABILIFYABILIFY MAINTENAABRAXANEACETAZOLAMIDE SODIUMACETYLCYSTEINE INJACTEMRA INJECTION (50242-0136-01,50242-0137-01)ACTEMRA 162mg/0.9ml Syringe (502420138-01)ACTHAR R YCINADRUCILJ7192ADVATEJ7192ADYNOVATE90656AFLURIA PRESERVATIVE FREE SUSPJ3262J326290658AFLURIA SUSPQ2035AFLURIA TAKINETON* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingPRIMARY CATEGORYTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJGENERIC NAMEAmphotericin B lipid complexAripiprazole, intramuscular, 0.25 mgApriprazole 300mg, IM injectionpaclitaxel protein-bound particles, 1 mgAcetazolamide sodium injectionAcetylcysteine injection, 10 mgTHERAPEUTIC INJTHERAPEUTIC INJTocilizumab 200mg, 400mgTHERAPEUTIC INJTocilizumab, 1 mgCorticotropin injectionHemophilus influenza b vaccine (Hib), PRP-T conjugate (4dose schedule), for intramuscular useCorticorelin ovine triflutalInterferon gamma 1-b 3 miillion unitsAlteplase recombinant, 1mgAcyclovir, 5 mgTdap vaccine, 7 yrs, IMPegademase bovine, 25 IUBrentuximab vedotin InjectionAdenosine 6 MGAdrenalin (epinephrine) injectDoxorubicin hcl 10 MGFluorouracil injection, 500 mgFactor VIII (antihemophilic factor, recombinant) per IU, nototherwise specifiedAntihemophilic Factor (Recombinant), PEGylated, is a humanantihemophilic factorInfluenza virus vaccine, split virus, preservative free, whenadministered to individuals 3 years and older, forintramuscular use (Code Price is per 0.5 mL dose) (Pleasenote: Agriflu is only indicated for use in patients 18 years ofage and older)Influenza virus vaccine, split virus, when administered toindividuals 3 years of age and older, for intramuscular use(Code price is per 0.5 mL based on Fluzone for patients 3through 17 years old) (For patients 18 years old and older.Influenza virus vaccine, split virus, when administered toindividuals 3 years of age and older, for intramuscular use(Afluria) see also 90656 and 90658Tirofiban HCl, 0.25 mgInfluenza virus vaccine, split virus, for intramuscular useHydrocortisone sodium succinateBiperiden lactate, per 5 mg1 of 31SECONDARY CATEGORYHOME HEALTH/INFUSION**SELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJIMMUNIZATIONSCHEMO ADJUNCT*HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**IMMUNIZATIONSHOME APYBLOOD/BLOOD PRODUCTS FORHEMOPHILIABLOOD/BLOOD PRODUCTS FORHEMOPHILIATHERAPEUTIC INJIMMUNIZATIONSTHERAPEUTIC INJIMMUNIZATIONSTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJIMMUNIZATIONSIMMUNIZATIONSCHEMO ADJUNCT*Rev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR CROSSWALKHCPCSJ1931DRUG NAMEALDURAZYMEJ9215ALFERON 186ALPHANATE VWFJ7193ALPHANINE SDJ7201ALPROLIXJ0270Alprostadil ETHAPREDAMEVIVEAMICARAMIKACIN SULF INJ USP 1GRAM/4MLFLIPTOP VIALAMIKINAMINOPHYLLINEAMIODARONE HCLAMPHADASE 150 UNIT/ML SOLNAMPHOCINAMPHOTECAMPHOTERICIN BAMPICILLIN SODIUMAMPICILLIN-SULBACTAMAMYTAL SODIUMANASCORPANCEFANECTINEANGIOMAXANTHRAX 430J0256J0390* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingPRIMARY CATEGORYTHERAPEUTIC INJSECONDARY CATEGORYHOME HEALTH/INFUSION**Interferon alfa-N3 (human leukocyte derived), 250,000 IU injPemetrexed, 10 mgMelphalan hydrochl 50 MGPalonosetron HCl, 25 mcgSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJFactor VIII (antihemophilic Factor [human]) per IUVon Willebrand Factor complex, human, ristocetin coFactor(not otherwise specified ), per I.U.Factor IX (antihemophilic Factor, purified, non-recombinant)per IUCoagulation Factor IX (Recombinant), Fc Fusion Protein],Lyophilized Powder for Solution for Intravenous InjectionInjection, alprostadil, 1.25 mcg (code may be used forMedicare when drug administered under direct physiciansupervision, not for use when drug is self-administered)Amphotericin B liposome injMethylprednisolone injectionMethylprednisolone injectionAlefaceptAminocaproic acidTHERAPEUTIC INJCHEMO ADJUNCT*CHEMOTHERAPYCHEMOTHERAPYCHEMO ADJUNCT*BLOOD/BLOOD PRODUCTS FORHEMOPHILIABLOOD/BLOOD PRODUCTS FORHEMOPHILIABLOOD/BLOOD PRODUCTS FORHEMOPHILIABLOOD/BLOOD PRODUCTS FORHEMOPHILIASELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJAmikacin sulfate injectionAmikacin sulfate injectionAminophyllin 250 MG injAmiodarone hclHyaluronidase, up to 150 unitsAmphotericin BAmpho b cholesteryl sulfateAmphotericin BAmpicillin 500 MG injAmpicillin sodium per 1.5 gmAmobarbital 125 MG injCentruroides immune f(ab)2, up to 120 milligramsCefazolin sodium injectionSuccinycholine chloride injBivalirudin, 1mgAnthrax vaccine, scFomepizole, 15 mgDolasetron mesylateApomorphine hydrochloride, 1mgVitamin K phytonadione injAlpha 1 proteinase inhibitorChloroquine injectionTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJLaronidase injectionGENERIC NAME2 of 31THERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJHOME HEALTH/INFUSION**CHEMO ADJUNCT*CHEMO ADJUNCT*HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**IMMUNIZATIONSCHEMO ADJUNCT*HOME HEALTH/INFUSION**Rev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR CROSSWALKHCPCSJ0380J0881J0882J2793J2430C9121C9399, J3490J3302J3303J3303J1652J9261J9302C9399, J3490J2275DRUG NAMEARAMINEARANESPARANESPARCALYSTAREDIAARGATROBAN 100 MG/ML SOLNARISTADAARISTOCORT FORTEARISTOSPAN INTRA-ARTICULARARISTOSPAN INTRALESIONALARIXTRAARRANON 5 MG/ML IVANATROPINE INE SODIUMBACLOFENBACTOCILL IN DEXTROSEBAL IN OIL90371BAYHEP D* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingGENERIC NAMEMetaraminol bitartrateDarbepoetin alfa, 1 microgram (non-ESRD use)Darbepoetin alfa, 1 microgram (for ESRD on dialysisRilonacept Injection 220 mg SolrPamidronate disodium /30 MGArgatroban, Per 5 mgAriprprazole lauroxilextended release suspensionTriamcinolone diacetate injTriamcinolone hexacetonl injTriamcinolone hexacetonl injFondaparinux sodium, 0.5 mgNelarabine, 50 MgOfatumumabPolidocanol InjectionMorphine sulfate injectionLymphocyte immune globulin, antithymocyte globulin, equine,parenteral, 250 mgLorazepam injectionAtropine sulfate injectionAntithrombin (Recombinant)LyophilizedMeasles vaccine, SCBevacizumab, 0.25 mgBevacizumab injection, 10 mgTestosterone undecanoate 250 mg/mlMoxifloxacin 100 mgInterferon beta-1A, 11 mcg for intramuscular use (See alsoJ1825)Interferon beta-1a, 33 mcgCeftazidime-avibactam InjectionAztreonam, 500 mgAzathioprine parenteralBaclofen 10 MG injectionOxacillin sodium injecitonDimecaprol injectionHepatitis B Immune Globulin (HBIg), human, forintramuscular use (Note: For billing HepaGam B use Q4090for IM use and 90399 for IV use)Rabies Immune Globulin (R IG), human, for intramuscularand/or subcutaneous useRh IG, minidose, IMPRIMARY CATEGORYTHERAPEUTIC ERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJRho d immune globulin, human, minidose, 50 mcg (250 iu)THERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLESELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSECONDARY CATEGORYCHEMO ADJUNCT*CHEMO ADJUNCT*CHEMO ADJUNCT*CHEMOTHERAPYCHEMOTHERAPYHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**BLOOD/BLOOD PRODUCTS HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**TRANSPLANT*HOME HEALTH/INFUSION**THERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJRho d immune globulin, human, minidose, 300 mcg (1500 iu) THERAPEUTIC INJ3 of 31Rev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR CROSSWALKHCPCSJ1670BAYTETDRUG NAMEJ7194BEBULIN BETASERON90620BEXSEROJ0558BICILLIN C-R ILLIN L-ABICILLIN L-ABICILLIN L-ABICNUBIVIGAMBLENOXANEBLEOMYCIN SULFATEBLINCYTOBONIVABOOSTRIXBOTOXBOTULINIM ANTITOXINBOTULISMBRAVELLEBRETHINEBROMPHENIRAMINE MALEATEBUMETANIDEBUPIVICAINEBUPRENEXBUSULFEX 6MG/MLBUTORPHANOL UM DISODIUM VERSENATECALCIUM GLUCONATE* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingGENERIC NAMETetanus immune globulin, human, up to 250 unitsPRIMARY CATEGORYTHERAPEUTIC INJFactor IX, complex, per IUBelinostat InjectionDiphenhydramine hcl injectionBendamustine HCI InjectionTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJFactor IX (antihemophilic Factor, recombinant) per IUBelimumab 10 mgDicyclomine injectionC1 Esterase Inhibitor (Human)Interferon beta-1b / .25 MGMeningococcal recombinant protein and outer membranevesicle vaccine, serogroup B, 2 dose schedule, forintramuscular useTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLEPenicillin G benzathine and penicillin G procaine, 25,000UPenicillin G benzathine, up to 600,000 unitsPenicillin G benzathine, up to 1,200,000 unitsPenicillin G benzathine, up to 2,400,000 unitsCarmustine, 100 mgImmune Globulin Intravenous (Human), 10% liquidBleomycin sulfate injection, 15 unitsBleomycin sulfate injection, 15 unitsBlinatumomab for Injection, IVIbandronate sodium Injection, 1 mgTdap vaccineOnabotulinumtoxinA, 1 unitBotulinim antitoxin, equine, any routeBotulism immune globulin, human, IVUrofollitropin, 75 iuTerbutaline sulfate injBrompheniramine maleate injBumetanide 0.5 mgBupivicaine hydroBuprenorphine hydrochlorideBusulfan injectionButorphanol tartrate 1 mgExenatide extended releaseExenatide InjectionCaffeine citrate injection, 5 MGCalcitriol per 0.1 mcgCalcitrol, 0.25 mgEdetate calcium disodium injCalcium gluconate injectionTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLESELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJ4 of 31THERAPEUTIC INJSECONDARY CATEGORYBLOOD/BLOOD PRODUCTS FORHEMOPHILIACHEMOTHERAPYCHEMO ADJUNCT*CHEMOTHERAPYBLOOD/BLOOD PRODUCTS FORHEMOPHILIAHOME HEALTH/INFUSION**IMMUNIZATIONSCHEMOTHERAPYHOME YHOME HEALTH/INFUSION**IMMUNIZATIONSINFERTILITYHOME HEALTH/INFUSION**CHEMOTHERAPYHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**Rev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR RUG CAINECARBOPLATINJ1566CARIMUNE NFJ1955J2997J0270CARNITORCATHFLO ACTIVASECAVERJECTJ0270CAVERJECT 13J0697J0697CEFADYLCEFAZOLIN SODIUMCEFIZOXCEFIZOX IN D5WCEFOPERAZONECEFOTAXIME SODIUMCEFOTETANCEFOXITIN SODIUMCEFTAZIDIMECEFUROXIME SODIUMCEFUROXIME-DEXTROSEJ0702CELESTONE SOLUSPANJ7599J1890CELLCEPT 500MGCEPHALOTHIN CHLOROPROCAINE HCLGENERIC NAMEInjection, ibuprofen, 100 mgCalcium glycer & lact/10 MLAlemtuzumab, 10 mgIrinotecan injection, 20mgCaspofungin acetateMepivacaine HCL/10 mlCarboplatin injectionImmune globulin, intravenous, lyophilized (eg powder), 500mgLevocarnitine per 1 gmAlteplase recombinant, 1 mgAlprostadil for injectionInjection, alprostadil, 1.25 mcg (code may be used forMedicare when drug administered under direct physiciansupervision, not for use when drug is self-administered)Cephapirin sodiumCefazolin sodium injectionCeftizoxime sodium / 500 MGCeftizoxime sodium / 500 MGCefoperazone sodiumCefotaxime sodium injectionCefotetan disodiumCefoxitin sodium injectionCeftazidime per 500 mgnjection, sterile cefuroxime sodium, per 750 mgSterile cefuroxime injectionBetamethasone acetate 3 mg and betamethasone sodiumphosphate 3 mgImmunosuppressive drug, not otherwise classifiedCephalothin sodium injectionPRIMARY CATEGORYTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLESECONDARY CATEGORYHOME HEALTH/INFUSION**CHEMOTHERAPYCHEMOTHERAPYHOME HEALTH/INFUSION**CHEMOTHERAPYHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**SELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**THERAPEUTIC INJCHEMO ADJUNCT*THERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTRANSPLANT*HOME HEALTH/INFUSION**BLOOD/BLOOD PRODUCTS FORHEMOPHILIAHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**CHEMOTHERAPYTHERAPEUTIC HENICOL SOD SUCCINATE Chloramphenicol sodium injectTHERAPEUTIC INJHOME HEALTH/INFUSION**Chloramphenicol sodium injectChloroprocaine hcl injectionTHERAPEUTIC INJTHERAPEUTIC INJHOME HEALTH/INFUSION*** If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingProtein C concentrate, intravenous, human, 10 IUCeftazidime per 500 mgFosphenytoin, 50 mg phenytoin equivalentFosphenytoin sodiumAlglucerase injectionImiglucerase, per unitDaunorubicin, 10 mgHuman Papillomavirus Bivalent (Types 16 and 18) Vaccine,RecombinantCetrorelix acetate for inj kit 0.25 mg5 of 31Rev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR 0515J0760J0770J0770J0780J1595J0282DRUG NAMECHLORPROMAZINE HCLCHOLERA VACCINECHORIONIC GONADOTROPINCIMZIACINQAIRCINRYZECIPROCIPRO IN D5WCISPLATINCISPLATINCLADRIBINECLAFORANCLAFORAN IN D5WCLEOCINCLEVIPREXCLOLARCOBAL-1000CODEINE PHOSPHATECOGENTINCOLCHICINECOLISTIMETHATE SODIUMCOLY-MYCIN MCOMPAZINECOPAXONECORDARONE IVJ7180CORIFACTJ0834J1742C9399, OSMEGENCosyntropin 0.25 MG YRAMZACYTARABINEC9399, J3590* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingGENERIC NAMEChlorpromazine hcl injectionCholera vaccine, injectableChorionic gonadotropin/1000uCertolizumab pegol, 1mgReslizumabInjection, C-1 esterase inhibitor (human), 10 unitsCiprofloxacin for intravenous infusion, 200 mgCiprofloxacin for intravenous infusion, 200 mgCisplatin 10 mg injectionCisplatin 50 mg injectionCladribine per 1 MGCefotaxime sodium injectionCefotaxime sodium injectionClindamycin phosphateClevidipine butyrate, 1 mgClofarabine injectionVitamin B-12 cyanocobalamin, up to 1,000mcgCodeine phosphate /30 MGBenztropine mesylate, 1 mgColchicine injectionColistimethate sodium injColistimethate sodium injProchlorperazine, up to 10 mgGlatiramer acetateAmiodarone hclPRIMARY CATEGORYTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLESELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJFactor XIII ConcentrateCosyntropin per 0.25 MGIbutilide fumarate injectionSecukinumab InjectionDactinomycin, 0.5 mgCosyntropin per 0.25 MGPrednisolone acetate injIsavuconazonium sulfate InjectionInjection, crotalidae polyvalent immune fab (Ovine), up to 1gramDaptomycin injectionVitamin B-12 cyanocobalamin, up to 1000mcgCyclophosphamide 100 MG injCyclophosphamide 200 MG injCyclophosphamide 500 MG injCyclophosphamide 1.0 grm injCyclophosphamide 2.0 grm injCyclosporine, parenteral, 250mgRamucirumab injection, for intravenous useCytarabine hcl 100 MG injTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJ6 of 31THERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSECONDARY CATEGORYIMMUNIZATIONSINFERTILITYHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME APYHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**CHEMOTHERAPYHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**CHEMO ADJUNCT*BLOOD/BLOOD PRODUCTS FORHEMOPHILIACHEMOTHERAPYCHEMO ADJUNCT*HOME CHEMOTHERAPYRev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR CROSSWALKHCPCSJ9110DRUG ECYTOXANCYTOXANCYTOXANCYTOXANCYTOXAND.H.E. ELC9399, J9999DARZALEXJ9150J9151J2597DAUNORUBICIN 8J1000J1020J1030J1040DEFEROXAMINE MESYLATEDEKASOLDEKASOL LADELATESTRYLDELATESTRYLDELATESTRYLDELESTROGEN 10 MG/MLDELESTROGEN 20MG/MLDELESTROGEN ROL 20DEPO-MEDROL 40DEPO-MEDROL 80* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingGENERIC NAMECytarabine, 500mgInjection, cytomegalovirus, immune globulin intravenous(human), CMV-IgIV intravenous, human, per vialInjection, cytomegalovirus, immune globulin intravenous(human), CMV-IgIV intravenous, human, per vialGanciclovir sodium injectionCyclophosphamide 100 MG injectionCyclophosphamide 200 MG injectionCyclophosphamide 500 MG injectionCyclophosphamide 1.0 grm injectionCyclophosphamide 2.0 grm injectionDihydroergotamine mesyltateDacarbazine 100 mg injectionDacarbazine 200 MG injectionDecitabine for InjectionDalbavancin hcl for iv soln 500 mgDiphtheria and Tetanus Toxoids and Acellular PertussisVaccine AdsorbedDaratumumab injection, for intravenous useDaunorubicin, 10 mgDaunorubicin citrate liposomal formulation, 10 mgDesmopressin acetate, per 1 mcgTetanus and diphtheria toxoids (Td) adsorbed, preservativefree, when administered to individuals 7 years or older, forintramuscular useTetanus and diphtheria toxoids (Td) adsorbed whenadministered to individuals 7 years or older, for intramuscularuseDeferoxamine mesylate injectionDexamethasone sodium phosphate 1 mgDexamethasone acetateTestosterone enanthate, 1 mgTestosterone enanthate injection, Up to 100mgTestosterone enanthate injection, Up to 200mgEstradiol valerate injection, Up to 10 MGEstradiol valerate injection, Up to 20 MGEstradiol valerate injection, Up to 40 MGTorsemide 10 mg/mlMeperidine hydrochlide /100 MGCytarabine liposome, 10 mgDepo-estradiol cypionate injectionMethylprednisolone 20 MG injectionMethylprednisolone 40 MG injectionMethylprednisolone 80 MG injection7 of 31PRIMARY CATEGORYTHERAPEUTIC INJSECONDARY CATEGORYCHEMOTHERAPYTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC THERAPYTHERAPEUTIC INJIMMUNIZATIONSTHERAPEUTIC INJCHEMOTHERAPYTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJCHEMOTHERAPYCHEMOTHERAPYTHERAPEUTIC INJIMMUNIZATIONSTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJIMMUNIZATIONSHOME HEALTH/INFUSION**CHEMO ADJUNCT*CHEMO HERAPYCHEMOTHERAPYCHEMOTHERAPYHOME HEALTH/INFUSION**HOME APYCHEMOTHERAPYRev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR 1094J1750J1190J7100J7100J7110J7110J7060J7070DRUG NAMEDEPO-PROVERA 150 MGDEPO-PROVERA 400 MGDEPO-SUBQ PROVERA 104DEPO-TESTOSTERONEDESFERALDESMOPRESSIN ACETATEDEXAMETHASONE ACETATEDEXAMETHASONE SODIUMPHOSPHATEDEXAMETHASONE SODIUMPHOSPHATEDEXASONE L.A.DEXFERRUMDEXRAZOXANEDEXTRAN 40 IN D5WDEXTRAN 40 IN NACLDEXTRAN 75 IN D5WDEXTRAN 75 IN NACLDEXTROSEDEXTROSEJ7121DEXTROSE in LACTATED RINGERS 5%J1100J1100GENERIC NAMEMedroxyprogesterone contraceptive injectionMedroxyprogesterone injection 1 mgMedroxyprogesterone acetate InjectionTestosterone cypionate, 1mgDeferoxamine mesylate injectionDesmopressin acetateDexamethasone acetatePRIMARY CATEGORYTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJDexamethasone sodium phosphate 1 mgTHERAPEUTIC INJCHEMO ADJUNCT*Dexamethasone sodium phosDexamethasone acetateIron dextran, 50 mgDexrazoxane hcl injectionDextran 40 infusionDextran 40 infusionDextran 75 infusionDextran 75 infusion5% Dextrose/waterInfusion, D5W, 1000 cc5% dextrose in lactated ringer's, 1000 mLTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJCHEMO ADJUNCT*CHEMO ADJUNCT*HOME HEALTH/INFUSION**CHEMO ADJUNCT*HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**THERAPEUTIC INJHOME HEALTH/INFUSION**THERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJDRUG IS NO LONGERMANUFACTUREDTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJHOME HEALTH/INFUSION**5% dextrose and 0.45% normal saline, 1000 mLS5010DEXTROSE-NaCL 5 – 0.45% SOLUTIONJ3360J0500DIAZEPAMDICYCLOMINE HCLDiazepam, up to 5 mgDicyclomine injectionJ1436DIDRONELEtidronate disodium AN IN SODIUM CHLORIDEDIGIBINDDIGIFABDIGOXINDIHYDROERGOTAMINE YDRAMINE HCLDIPHTHERIA TOXOIDDIPHTHERIA-TETANUS TOXOIDSDIPHTHERIA-TETANUS TOXOIDSDIPRIVANDIPTHERIA ANTITOXINDIPYRIDAMOLE INJECTIONDIURIL IVFluconazoleDigoxin immune fab (ovine)Digoxin immune fab (ovine)Digoxin injectionDihydroergotamine mesyltateHydromorphone injectionHydromorphone injectionDyphylline injectionDimenhydrinate injectionDiphenhydramine hcl injectionDiphtheria toxoid, IMDT vaccine 7 yrs, IMTd vaccine 7, IMPropofol, 10 mgDiptheria antitoxin, equine any routeDipyridamole injectionChlorothiazide sodium, per 500 mg* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home setting8 of 31SECONDARY CATEGORYCHEMO ADJUNCT*HOME HEALTH/INFUSION**CHEMO ADJUNCT*HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**CHEMO ADJUNCTIMMUNIZATIONSIMMUNIZATIONSIMMUNIZATIONSHOME HEALTH/INFUSION**Rev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR 0723J9130J9130J0735J2270DRUG NAMEDOBUTAMINE HCLDOPAMINE HCLDOPAMINE HCL 200MG IN 5%DEXTROSEDOPAMINE HCL 800MG IN 5%DEXTROSEDOPAMINE IN D5WDORIBAXDOXILDROPERIDOLDROPERIDOL/FENTANYL CITRATEDTAP-HEP B-IPV TEDETATE ITEKELLENCEELLIOTTS BJ7205ELOCTATEJ9263J9020J1453J0350C9399, J9999J1438ELOXATINELSPAREMEND 115 MG * If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingGENERIC NAMEDobutamine HCL 250 mgDopamine hcl, 40 mg injectionPRIMARY CATEGORYTHERAPEUTIC INJTHERAPEUTIC INJDopamine injectionTHERAPEUTIC INJDopamine injectionDopamine injectionDoripenem, 10 mgDoxorubicin hydrochloride, liposomal, Doxil, 10 mgDroperidol injectionDroperidol/fentanyl injectionDtap-Hep B-Ipv Vaccine, IMDacarbazine 100 mg injectionDacarbazine 200 MG injectionClonidine hydrochlorideMorphine sulfate, up to 10 mgMorphine sulfate, preservative-free for epidural or intrathecaluse, 10mgMorphine sulfate injectionMorphine sulfate, preservative-free for epidural or intrathecaluse, 10 mgAbobotulinumtoxinA, 5 unitsEdetate disodium /150 mgInjection, alprostadil, 1.25 mcg (code may be used forMedicare when drug administered under direct physiciansupervision, not for use when drug is self-administered)Tesamorelin for injectionIdursulfase,1 mgAmitriptyline injectionTaliglucerase alfa InjectionLeuprolide acetate suspensionRasburicase, 0.5 mgEpirubicin hcl, 2 mgElliotts b solution per mlTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJAntihemophilic Factor (Recombinant), Fc Fussion Protein],Lyophilized Powder for Solution For Intravenous InjectionOxaliplatinAsparaginase injection, 10,000 unitsFosaprepitant, 1 mgAnistreplase 30 uElotuzumab for Intravenous infusionEtanercept injectionHepatitis B vaccine, dialysis or immunosuppressed patientdosage (3-dose schedule), for intramuscular use9 of 31THERAPEUTIC INJTHERAPEUTIC INJSECONDARY CATEGORYCHEMOTHERAPYHOME HEALTH/INFUSION**HOME RAPYHOME HEALTH/INFUSION**HOME HEALTH/INFUSION**HOME HEALTH/INFUSION**THERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLESELF-INJECTABLETHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJHIV/AIDSHOME HEALTH/INFUSION**CHEMOTHERAPYCHEMO ADJUNCT*CHEMOTHERAPYCHEMOTHERAPYBLOOD/BLOOD PRODUCTS FORHEMOPHILIATHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC INJSELF-INJECTABLECHEMOTHERAPYCHEMOTHERAPYCHEMO ADJUNCT*THERAPEUTIC INJIMMUNIZATIONSCHEMOTHERAPYRev.4/14/16Effective 7/13/16
INJECTABLE MEDICATION HCPCS/DOFR CROSSWALKHCPCS90746ENGERIX-BDRUG NAME90744ENGERIX-B 10 MCG/0.5ML INJ90747ENGERIX-B 20 MCG/ML INJJ3380J0171J3490J3490J0885ENTYVIOEPINEPHRINE HCLEPIPENEPIPEN ERAXIS 50 MGERBITUXERGONOVINE MALEATEERWINAZEERYTHROCINERYTHROMYCIN LACTOBIONATEESTRADIOL VALERATE 10 AEVZIOEXPARELEXTAVIAEYLEAFABRAZYMEFASLODEXFEIBA VH IMMUNO (ANTI-INHIBITORCOAGULANT COMPLEX)FENTANYL CITRATEFENTANYL-DROPERIDOLQ0138FERAHEME INJECTIONQ0139FERAHEME 399/J3490C9290J1830J0178J0180J9395J7198* If associated with a cancer Dx ICD‐9** When administered by a nurse in a home settingGENERIC NAMEHepatitis B vaccine, adult dosage, for intramuscular useHepatitis B vaccine, pediatric/adolescent dosage (3-doseschedule), for intramuscular useHepatitis B vaccine, dialysis or immunosuppressed patientdosage (4-dose schedule), for intramuscular useVedolizumab for injection, for intravenous useAdrenalin epinephrine injectEpinephrine hcl injection device 1:1000Epinephrine hcl injection device 1:1000Epoetin alfa, (for non-ESRD use), 1000 unitsEpoetin alfa, 1000 units (for ESRD on dialysis) (renal dialysisfacilities and hospitals must use code Q4081 effective 1/1/07)PRIMARY CATEGORYTHERAPEUTIC INJSECONDARY CATEGORYIMMUNIZATIONSTHERAPEUTIC INJIMMUNIZATIONSTHERAPEUTIC INJTHERAPEUTIC INJTHERAPEUTIC MUNIZATIONSSELF-INJECTABLEEpoetin Alfa, 100 Units (For ESRD On Dialysis) (For RenalDialysis Facilities And Hospital Use)Anadulafungin injectionCetuximab injectionErgonovine maleate injecti
C9257 AVASTIN Bevacizumab, 0.25 mg THERAPEUTIC INJ CHEMOTHERAPY J9035 AVASTIN Bevacizumab injection, 10 mg THERAPEUTIC INJ CHEMOTHERAPY J3145 AVEED Testosterone undecanoate 250 mg/ml THERAPEUTIC INJ J2280 AVELOX Moxifloxacin 100 mg THERAPEUTIC INJ HOME HEALTH/INFUSION** Q3025 AVONEX
