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Provider Bulletin – April 2017A bulletin for the Molina Healthcare of New York, Inc. Network(Formerly Total Care, A Today’s Options of New York Health Plan)Questions?Call Provider Services(877) 872-4716Monday through Thursday8:00 a.m.-5:00 p.m.Friday9:00 a.m.-5:00 p.m.Molina Healthcare Provider Update - NDC RequirementWhen billing for physician-administered drugs in a non-inpatient setting, New York State Dept. of Health is requiringNational Drug Code (NDC) be included when HCPCS Codes (J0000-J9999) are reported without a UD modifier.This NDC requirement also includes BETOS Codes (O1E/O1D) for physician-administered drugs in a non-inpatient settingand reported without a UD modifier.The O1E and O1D codes represent Chemotherapy and ‘Other Drugs’ that would fall into the categorization of ‘PhysicianAdministered Drugs’. Per the attached list from NYS, these are A-Codes, C-Codes, G-Codes, and Q-Codes.Below is a summary of the system edit modification to include the BETOS codes that will be applied to our claimsprocessing as of 4/1/17. If a J-Code (HCPCS) is submitted for a physician-administered drug in a non-inpatient setting and theProcedure Code Modifier is not ‘UD’, a valid NDC must be included. A procedure code is considered a J-Code when;1) HCPCS procedure codes equal J0000 through J9999OR2) BETOS codes (from HCPCS file) equal O1E and O1DMCD PV PRUPNDC 0317 03/15/2017
9002J9015J9017MCD PV PRUPNDC 0317 03/15/2017LONG DESCRIPTIONInjection, obinutuzumab, 10mgInjection, ramucirumab, 5 mgInjection, ado-trastuzumabemtansine, 1 mgInjection, brentuximabvedotin, 1 mg(i.u.)Injection, pertuzumab, 10 mgInjection, carfilzomib, 1 mgInjection, ziv-aflibercept, 1 mgInjection, omacetaxinemepesuccinate, 0.01 mgInjection, belinostat, 10 mgInjection, blinatumomab, 1mcgInjection, nivolumab, 1 mgInjection, siltuximab, 10 mgInjection, amifostine, 500 mgInjection, dolasetron mesylate,10 mgAntiemetic drug,rectal/suppository, nototherwise specifiedBusulfan; oral, 2 mgCapecitabine, oral, 150 mgCapecitabine, oral, 500 mgCyclophosphamide; oral, 25mgEtoposide; oral, 50 mgFludarabine phosphate, oral,10 mgAntiemetic drug, oral, nototherwise specifiedMelphalan; oral, 2 mgMethotrexate; oral, 2.5 mgTemozolomide, oral, 5 mgTopotecan, oral, 0.25 mgPrescription drug, oral,chemotherapeutic, nosInjection, doxorubicinhydrochloride, 10 mgInjection, doxorubicinhydrochloride, liposomal,doxil, 10 mgInjection, aldesleukin, persingle use vialInjection, arsenic trioxide, 1mgSHORT DESCRIPTIONInjection, obinutuzumabBETOSO1DInjection, ramucirumabIn ado-trastuzumab emtansineO1DO1DInj, brentuximab vedotinO1DInj, erwinia chrysanthemiInjection, pertuzumabInjection, carfilzomibInjection, ziv-afliberceptOmacetaxine mepesuccinateO1DO1DO1DO1DO1DInjection, belinostatInj, blinatumomabO1DO1DInjection, nivolumabInjection, siltuximabAmifostineDolasetron mesylateO1DO1DO1DO1DAntiemetic rectal/supp nosO1DOral busulfanCapecitabine, oral, 150 mgCapecitabine, oral, 500 mgCyclophosphamide oral 25 mgO1DO1DO1DO1DEtoposide oral 50 mgOral fludarabine phosphateO1DO1DAntiemetic drug oral nosO1DMelphalan oral 2 mgMethotrexate oral 2.5 mgTemozolomideTopotecan oralOral prescription drug chemoO1DO1DO1DO1DO1DDoxorubicin hcl injectionO1DDoxil injectionO1DAldesleukin injectionO1DArsenic trioxide injectionO1D
J9207J9208J9209J9211MCD PV PRUPNDC 0317 03/15/2017Injection, asparaginase(erwinaze), 1,000 iuInjection, asparaginase, nototherwise specified, 10,000unitsInjection, azacitidine, 1 mgBcg (intravesical) perinstillationInjection, belinostat, 10 mgInjection, bendamustine hcl, 1mgInjection, blinatumomab, 1microgramInjection, bleomycin sulfate,15 unitsInjection, brentuximabvedotin, 1 mgInjection, cabazitaxel, 1 mgInjection, carboplatin, 50 mgInjection, carfilzomib, 1 mgInjection, carmustine, 100 mgInjection, cisplatin, powder orsolution, 10 mgInjection, cladribine, per 1 mgCyclophosphamide, 100 mgInjection, cytarabine, 100 mgInjection, dactinomycin, 0.5mgDacarbazine, 100 mgInjection, daunorubicin, 10 mgInjection, daunorubicin citrate,liposomal formulation, 10 mgInjection, diethylstilbestroldiphosphate, 250 mgInjection, eribulin mesylate,0.1 mgInjection, etoposide, 10 mgInjection, fludarabinephosphate, 50 mgInjection, fluorouracil, 500 mgInjection, floxuridine, 500 mgInjection, gemcitabinehydrochloride, 200 mgGoserelin acetate implant, per3.6 mgInjection, irinotecan, 20 mgInjection, ixabepilone, 1 mgInjection, ifosfamide, 1 gramInjection, mesna, 200 mgInjection, idarubicinhydrochloride, 5 mgErwinaze injectionO1DAsparaginase, nosO1DAzacitidine injectionBcg live intravesical vacO1DO1DInjection, belinostat, 10mgBendamustine injectionO1DO1DInjection, blinatumomabO1DBleomycin sulfate injectionO1DBrentuximab vedotin injO1DCabazitaxel injectionCarboplatin injectionInjection, carfilzomib, 1 mgCarmustine injectionCisplatin 10 mg injectionO1DO1DO1DO1DO1DInj cladribine per 1 mgCyclophosphamide 100 mg injCytarabine hcl 100 mg injDactinomycin injectionO1DO1DO1DO1DDacarbazine 100 mg injDaunorubicin injectionDaunorubicin citrate injO1DO1DO1DDiethylstilbestrol injectionO1DEribulin mesylate injectionO1DEtoposide injectionFludarabine phosphate injO1DO1DFluorouracil injectionFloxuridine injectionGemcitabine hcl injectionO1DO1DO1DGoserelin acetate implantO1DIrinotecan injectionIxabepilone injectionIfosfamide injectionMesna injectionIdarubicin hcl injectionO1DO1DO1DO1DO1D
J9308J9310MCD PV PRUPNDC 0317 03/15/2017Injection, interferon, alfa-2a,recombinant, 3 million unitsInjection, interferon, alfa-2b,recombinant, 1 million unitsInjection, interferon, alfa-n3,(human leukocyte derived),250,000 iuInjection, interferon, gamma1-b, 3 million unitsLeuprolide acetate (for depotsuspension), 7.5 mgLeuprolide acetate, per 1 mgLeuprolide acetate implant, 65mgHistrelin implant (vantas), 50mgHistrelin implant (supprelin la),50 mgInjection, ipilimumab, 1 mgInjection, mechlorethaminehydrochloride, (nitrogenmustard), 10 mgInjection, melphalanhydrochloride, 50 mgMethotrexate sodium, 5 mgMethotrexate sodium, 50 mgInjection, omacetaxinemepesuccinate, 0.01 mgInjection, oxaliplatin, 0.5 mgInjection, paclitaxel, 30 mgInjection, pegaspargase, persingle dose vialInjection, paclitaxel, 1 mgInjection, pentostatin, 10 mgInjection, plicamycin, 2.5 mgInjection, pembrolizumab, 1mgInjection, mitomycin, 5 mgInjection, mitoxantronehydrochloride, per 5 mgInjection, nivolumab, 1 mgInjection, gemtuzumabozogamicin, 5 mgInjection, obinutuzumab, 10mgInjection, ofatumumab, 10 mgInjection, panitumumab, 10mgInjection, pertuzumab, 1 mgInjection, ramucirumab, 5 mgInjection, rituximab, 100 mgInterferon alfa-2a injO1DInterferon alfa-2b injO1DInterferon alfa-n3 injO1DInterferon gamma 1-b injO1DLeuprolide acetate suspnsionO1DLeuprolide acetate injecitonLeuprolide acetate implantO1DO1DVantas implantO1DSupprelin la implantO1DIpilimumab injectionMechlorethamine hcl injO1DO1DInj melphalan hydrochl 50 mgO1DMethotrexate sodium injMethotrexate sodium injInj, omacetaxine mep, 0.01mgO1DO1DO1DOxaliplatinPaclitaxel injectionPegaspargase injectionO1DO1DO1DPaclitaxel injectionPentostatin injectionPlicamycin (mithramycin) injInj pembrolizumabO1DO1DO1DO1DMitomycin injectionMitoxantrone hydrochl / 5 mgO1DO1DInjection, nivolumabGemtuzumab ozogamicin injO1DO1DObinutuzumab injO1DOfatumumab injectionPanitumumab injectionO1DO1DInjection, pertuzumab, 1 mgInjection, ramucirumabRituximab injectionO1DO1DO1D
Q0165MCD PV PRUPNDC 0317 03/15/2017Injection, romidepsin, 1 mgInjection, streptozocin, 1 gramInjection, temozolomide, 1 mgInjection, temsirolimus, 1 mgInjection, thiotepa, 15 mgInjection, topotecan, 0.1 mgInjection, ado-trastuzumabemtansine, 1 mgInjection, vinblastine sulfate, 1mgVincristine sulfate, 1 mgInjection, vincristine sulfateliposome, 1 mgInjection, vinorelbine tartrate,10 mgInjection, porfimer sodium, 75mgNot otherwise classified,antineoplastic drugssubcutaneous, intramuscular,push), per visitChemotherapy administrationby infusion technique only, pervisitChemotherapy administrationby both infusion techniqueand other techique(s) (e.g.,subcutaneous, intramuscular,push), per visitemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosagea complete therapeuticsubstitute for an iv anti-emeticat the time of chemotherapytreatment, not to exceed a 48hour dosage regimenanti-emetic, for use as acomplete therapeuticsubstitute for an iv antiemetic at time ofchemotherapy treatment notto exceed a 48 hour dosageemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofRomidepsin injectionStreptozocin injectionTemozolomide injectionTemsirolimus injectionThiotepa injectionTopotecan injectionInj, ado-trastuzumab emt 1mgO1DO1DO1DO1DO1DO1DO1DVinblastine sulfate injO1DVincristine sulfate 1 mg injInj, vincristine sul lip 1mgO1DO1DVinorelbine tartrate injO1DPorfimer sodium injectionO1DChemotherapy drugO1DChemo by other than infusionO1DChemotherapy by infusionO1DChemo by both infusion and oO1DChlorpromazine hcl 5mg oralO1DOndansetron oralO1DDiphenhydramine hcl 50mgO1DProchlorperazine maleate 5mgO1DProchlorperazine maleate10mgO1D
chemotherapy treatment, notto exceed a 48 hour 4Q0175MCD PV PRUPNDC 0317 03/15/2017emetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 24 hour dosagea complete therapeuticsubstitute for an iv anti-emeticat the time of chemotherapytreatment, not to exceed a 48hour dosage regimencomplete therapeuticsubstitute for an iv anti-emeticat the time of chemotherapytreatment, not to exceed a 48hour dosage regimenemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageprescription anti-emetic, foruse as a complete therapeuticsubstitute for an iv anti-emeticat the time of chemotherapytreatment, not to exceed a 48hour dosage regimenemetic, for use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageas a complete therapeuticsubstitute for an iv anti-emeticat the time of chemotherapytreatment, not to exceed a 48hour dosage regimenGranisetron hcl 1 mg oralO1DDronabinol 2.5mg oralO1DDronabinol 5mg oralO1DPromethazine hcl 12.5mg oralO1DPromethazine hcl 25 mg oralO1DChlorpromazine hcl 10mg oralO1DChlorpromazine hcl 25mg oralO1DTrimethobenzamide hcl 250mgO1DThiethylperazine maleate10mgO1DPerphenazine 4mg oralO1D
A9150C9022C9023C9026C9027C9113C9121C9130C9132MCD PV PRUPNDC 0317 03/15/2017a complete therapeuticsubstitute for an iv anti-emeticat the time of chemotherapytreatment, not to exceed a 48hour dosage regimenfor use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageregimenfor use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 48 hour dosageregimenfor use as a completetherapeutic substitute for an ivanti-emetic at the time ofchemotherapy treatment, notto exceed a 24 hour dosageregimenuse as a complete therapeuticsubstitute for a iv anti-emeticat the time of chemotherapytreatment, not to exceed a 48hour dosage regimenInjection, teniposide, 50 mgInjection, doxorubicinhydrochloride, liposomal,doxil, 10 mgInjection, doxorubicinhydrochloride, liposomal,imported lipodox, 10 mgmgSterile saline or water,metered dose dispenser, 10mlNon-prescription drugsInjection, elosulfase alfa, 1mgInjection, testosteroneundecanoate, 1 mgInjection, vedolizumab, 1 mgInjection, pembrolizumab, 1mgInjection, pantoprazolesodium, per vialInjection, argatroban, per 5mgInjection, immune globulin(bivigam), 500 mgactivityPerphenazine 8mg oralO1DHydroxyzine pamoate 25mgO1DHydroxyzine pamoate 50mgO1DDolasetron mesylate oralO1DUnspecified oral anti-emeticO1DTeniposide, 50 mgDoxil injectionO1DO1DImported lipodox injO1DDoxorubicin inj 10mgSterile saline or waterO1DO1EMisc/exper non-prescript druInjection, elosulfase alfaInj testosterone undecanoateO1EO1EO1EInjection, vedolizumabInjection, pembrolizumabO1EO1EInj pantoprazole sodium, viaO1EInjection, argatrobanO1EInjection, ivig bivigamO1EKcentra, per i.u.O1E
C9367C9368C9369C9399C9441C9443MCD PV PRUPNDC 0317 03/15/2017Factor ix (antihemophilicfactor, recombinant), rixubis,per i.u.Factor xiii (antihemophilicfactor, recombinant), tretten,per 10 i.u.Factor ix (antihemophilicfactor, recombinant), alprolix,per i.u.Injection, factor viii, fc fusionprotein, (recombinant), per i.u.Injection, clevidipine butyrate,1 mgmlInjection, lacosamide, 1 mgInjection, bevacizumab, 0.25mgInjection, hexaminolevulinatehydrochloride, 100 mg, perstudy doseInjection, ibuprofen, 100 mgLidocaine 70 mg/tetracaine 70mg, per patchInjection, belatacept, 1 mgInjection, centruroides(scorpion) immune f(ab)2(equine), 1 vialInjection, bupivacaineliposome, 1 mgInjection, aflibercept, 2 mg vialInjection, glucarpidase, 10unitsInjection, taliglucerase alfa, 10unitsInjection, ocriplasmin, 0.125mgPuraply, and puraplyantimicrobial, any type, persquare centimeterEpifix, per square centimeterSkin substitute, endoformdermal template, per squarecentimeterGrafix core, per squarecentimeterGrafix prime, per squarecentimeterUnclassified drugs orbiologicalsInjection, ferriccarboxymaltose, 1 mgInjection, dalbavancin, 10 mgFactor ix recombinantO1EFactor xiii a-subunit recombO1EFactor ix (alprolix)O1EFactor viii (eloctate)O1EInj, clevidipine butyrateO1EArtiss fibrin sealantInjection, lacosamideBevacizumab injectionO1EO1EO1EHexaminolevulinate hclO1EInjection, ibuprofenPatch, lidocaine/tetracaineO1EO1EInjection, belataceptInj, centruroides (scorpion)O1EO1EInj, bupivacaine liposomeO1EInjection, afliberceptInjection, glucarpidaseO1EO1EInj, taliglucerase alfaO1EInjection, ocriplasminO1EPuraply, puraply antimicO1EEpifix wound coverEndoform dermal templateO1EO1EGrafix coreO1EGrafix primeO1EUnclassified drugs or biologO1EInj, ferric carboxymaltoseO1EInjection, dalbavancinO1E
G9019G9020G9033MCD PV PRUPNDC 0317 03/15/2017Injection, oritavancin, 10 mgInjection, c-1 esteraseinhibitor (recombinant),ruconest, 10 unitsInjection, tedizolid phosphate,1 mgInjection, phenylephrine andketorolac, 4 ml vialNetupitant 300 mg andpalonosetron 0.5 mg, oralInjection, fluocinoloneacetonide intravitreal implant,0.01 mgInjection, peramivir, 1 mgInjection, ceftolozane 50 mgand tazobactam 25 mgInjection, pasireotide longacting, 1 mgInjection, isavuconazoniumsulfate, 1 mgInjection, sulfur hexafluoridelipid microsphere, per mlFlorbetaben f18, diagnostic,per study dose, up to 8.1millicuriesFlutemetamol f18, diagnostic,per study dose, up to 5millicuriesInjection, cangrelor, 1 mgLoxapine, inhalation powder,10 mg(e.g., magnetic band)Injection procedure forsacroiliac joint; arthrograpyInjection procedure forsacroiliac joint; provision ofanesthetic, steroid and/orother therapeutic agent, withor without arthrographyapproved demonstrationproject)Zanamivir, inhalation powder,administered through inhaler,per 10 mg (for use in amedicare-approveddemonstration project)demonstration project)approved demonstrationproject)approved demonstrationproject)Injection, oritavancinC-1 esterase, ruconestO1EO1EInj, tedizolid phosphateO1EInj, phenylephrine ketorolacO1EOral netupitant palonosetronO1EFluocinolone acetonide impltO1EInjection, peramivirInj, ceftolozane/tazobactamO1EO1EInj, pasireotide long actingO1EInj, isavuconazonium sulfateO1ELumason contrast agentO1EFlorbetaben f18O1EFlutemetamol f18O1EInjection, cangrelorLoxapine, inhalation powderO1EO1ELap esoph augmentationInject for sacroiliac jointO1EO1EInj for sacroiliac jt anesthO1EAmantadine hcl 100mg oralO1EZanamivir,inhalation pwd 10mO1EOseltamivir phosphate 75mgRimantadine hcl 100mg oralO1EO1EAmantadine hcl oral brandO1E
J0205MCD PV PRUPNDC 0317 03/15/2017Zanamivir, inhalation powder,administered through inhaler,brand, per 10 mg (for use in amedicare-approveddemonstration project)approved demonstrationproject)approved demonstrationproject)Injection, tetracycline, up to250 mgadministered under the directsupervision of a physician, notfor use when drug is selfadministered)Injection abciximab, 10 mgInjection, acetaminophen, 10mgInjection, acetylcysteine, 100mgInjection, acyclovir, 5 mgInjection, adalimumab, 20 mgInjection, adenosine fortherapeutic use, 6 mg (not tobe used to report anyadenosine phosphatecompounds, instead usea9270)Injection, adenosine fordiagnostic use, 1 mg (not tobe used to report anyadenosine phosphatecompounds, instead usea9270)Injection, adenosine fordiagnostic use, 30 mg (not tobe used to report anyadenosine phosphatecompounds; instead usea9270)phosphate compounds)Injection, adrenalin,epinephrine, 0.1 mgInjection, aflibercept, 1 mgInjection, agalsidase beta, 1mgInjection, biperiden lactate,per 5 mgInjection, alatrofloxacinmesylate, 100 mgInjection, alemtuzumab, 1 mgInjection, alglucerase, per 10unitsZanamivir, inh pwdr, brandO1EOseltamivir phosp, brandO1ERimantadine hcl, brandO1ETetracyclin injectionO1EAbatacept injectionO1EAbciximab injectionAcetaminophen injectionO1EO1EAcetylcysteine injectionO1EAcyclovir injectionAdalimumab injectionInjection adenosine 6 mgO1EO1EO1EInj adenosine diag 1mgO1EAdenosine injectionO1EAdenosine inj 1mgAdrenalin epinephrine injectO1EO1EAflibercept injectionAgalsidase beta injectionO1EO1EInj biperiden lactate/5 mgO1EAlatrofloxacin mesylateO1EInjection, alemtuzumabAlglucerase injectionO1EO1E
J0350J0360J0364J0365MCD PV PRUPNDC 0317 03/15/2017Injection, methyldopate hcl, upto 250 mgInjection, alefacept, 0.5 mgInjection, alglucosidase alfa,10 mg, not otherwise specifiedInjection, alglucosidase alfa,(lumizyme), 10 mgmgInjection, alpha 1 proteinaseinhibitor (human), (glassia), 10mgdrug administered under thedirect supervision of aphysician, not for use whendrug is self administered)drug administered under thedirect supervision of aphysician, not for use whendrug is self administered)Injection, amikacin sulfate,100 mgInjection, aminophyllin, up to250 mgInjection, amiodaronehydrochloride, 30 mgInjection, amphotericin b, 50mgInjection, amphotericin b lipidcomplex, 10 mgInjection, amphotericin bcholesteryl sulfate complex,10 mgInjection, amphotericin bliposome, 10 mgInjection, ampicillin sodium,500 mgInjection, ampicillinsodium/sulbactam sodium,per 1.5 gmInjection, amobarbital, up to125 mgInjection, succin
If a J-Code (HCPCS) is submitted for a physician-administered drug in a non-inpatient setting and the Procedure Code Modifier is not ‘UD’, a valid NDC must be included. A procedure code is considered a J-Code when; 1) HCPCS procedure codes equal J0000 through J9
