J code list and How to Bill J Codes Correctly by the “UNITS” with example -

This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button.

Billing J code examples

cpt code and description


J0702 - Injection, betamethasone acetate 3mg and betamethasone sodium phosphate 3mg

J1030 - Injection, methylprednisolone acetate, 40 mg

J1100 - Injection, dexamethasone sodium phosphate, 1mg 

j3301 INJECTION TRIAMCINOLONE ACETONIDE NOS 10 MG


Example#1: J1100-Dexamethasone, 1 mg Your bottle says 4 mg/ml

If you use 0.25 cc (1 mg) = 1 Unit
If you use 0.5 cc (2 mg) = 2 Units
If you use 0.75 cc (3 mg) = 3 Units
If you use 1.0 cc (4 mg) = 4 Units

Example#2 J1030 methylprednisolone acetate, 40 mg (Depo-Medrol)

Your bottle says 40 mg/ml

If you use 0.25 cc 10 mg = 1 Unit
If you use 0.5 cc 20 mg = 1 Unit
(J1020=methylprednisolone acetate, 20 mg )
If you use 0.75 cc 30 mg = 1 Unit
If you use 1.0 cc 40 mg = 1 Unit

Example#3 J3301 triamcinolone acetonide, (Kenalog-10, Kenalog-40) per 10 mg

Your bottle says Kenalog 40 =40 mg/ml

If you use 0.25 cc 10 mg/40 mg = 1 Unit
If you use 0.5 cc 20 mg/40 mg = 2 Units
If you use 0.75 cc 30 mg/40 mg = 3 Units
If you use 1.0 cc 40 mg/40 mg = 4 Units

The CPT code J3301, Kenalog injection is a good example of an NOC code that must be used. Read the user manual for instructions for submitting NDC numbers. You need to change your insurance layout and enter the NDC number using the format specified in the user manual.

To report the Kenalog, use the HCPCS code J3301. This J code is for triamcinolone acetonide per 10mg. The instructions for this code state to use for Kenalog- 10, Kenalog-40, Triam-A. This code may be billed in multiple units. Thus, if 20mg were used, report J3301 with 2 in the units box (box 24G on the CMS -1500 form).

Example#4 J0702 betamethasone acetate and betamethasone phosphate, per 3 mg

(Celestone Soluspan 6 mg/ml)

If you use 0.25 cc 1.5 mg/6 mg = 1 Unit
If you use 0.5 cc 3 mg/6 mg = 1 Unit
If you use 0.75 cc 4.5 mg/6 mg = 1 Unit
If you use 1.0 cc 6 mg/6 mg = 2 Units



CPT CODE J2001  INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG 

the following services will not be eligible for separate reimbursement when identified as services that are included in the global surgical package when they are reported by the surgeon or by providers of the same group with the same specialty Please refer to the Bundled Services and Supplies Policy for additional information:

Fluid and drug administration services such as therapeutic, prophylactic, and/or local anesthetic injections (e.g., J2001 and 96372)



J2001 Redundant/Mutually

Exclusive

20526 8520527 20550 20551 20552 20553 20555 20555  20600 20605 20610 20612 20615  27096 64479 64480 64483 64484  64490 64491 64492  64493


Anthem Central Region bundles J2001 as redundant/mutually exclusive to 20526-20527, 20550-20555, 20600-20615, 27096, 64479, 64480-64484, 64490-64495. Based on the National Correct Coding Initiative Edits, code J2001 is listed as a component code to codes 20526-20527, 20550-20553, 20600- 20615, 27096, 64479, 64483, 64490-64495. Therefore, if J2001 is submitted with 20526-20527, 20550- 20555, 20600-20615, 27096, 64479, 64480-64484, 64490-64495—only 20526-20527, 20550-20555, 20600-20615, 27096, 64479, 64480-64484, 64490-64495 reimburses .

• In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationship examples:

J2001 reported with 20526-20615, 27096, 64470-64495




Units calculation example

The following are key points to remember when billing Medicare for rituximab (J9310):

• J9310 is defined in the HCPCS manual as: Injection, rituximab, 100 mg

• One (1) unit represents 100 mg of rituximab ordered/administered per patient

• Rituximab should be billed based on units not the total number of milligrams

o For example, if the quantity administered is 200 mg and the description of the drug code is 100 mg, the units billed should be two (2).



The following are key points to remember when billing Medicare for bevacizumab (J9035 or C9257):

• C9257 is defined in the HCPCS manual as: Injection, bevacizumab, 0.25 mg

• J9035 is defined in the HCPCS manual as: Injection, bevacizumab, 10 mg

• One (1) unit represents 10 mg of (J9035) or 0.25 mg (C9257) of bevacizumab ordered/administered per patient

• Bevacizumab should be billed based on unit not the total number of milligrams

o For example, if the quantity administered is 300mg and the description of the drug code is 10 mg, the units billed should be thirty (30).



Supplemental Information Related to Reporting Drugs

The following serves to clarify billing guidelines and provide examples of proper billing with a  singledose vial and discarded drug billing:

• Providers and hospitals are reminded to ensure that amounts of drugs administered to patients are accurately reported in terms of the dosage specified in the long descriptors for the applicable HCPCS codes. This is because the short descriptors are limited to 28 characters so they do not always capture the complete description of the drug.

• When submitting Medicare claims, units should be reported in multiples of the dosage included in
the long HCPCS descriptor. If the dosage given is not a multiple of the number provided in the HCPCS code description, the provider shall round up to the nearest whole number in order to
express the number as a multiple.

• If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Medicare may cover the amount of the drug discarded along with the amount administered. The following elements must be followed in order for the discarded amount to be covered.

1. The vial must be a single-use vial. Multi-use vials are not subject to payment for any discarded amounts of the drug.

2. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient code is 10 mg, the units billed should be thirty (30).

Physician Drug List by Name

The following table provides a listing of valid physician drug codes sorted alphabetically by name. To view this list sorted numerically, refer to Section H.3, Physician Drug List by Procedure Code.

The inclusion or exclusion of a procedure code on this list does not imply  Medicaid coverage, reimbursement, or lack thereof. To inquire regarding any restrictions/limits on these procedure codes, please consult the Provider Assistance Center at 1-800-688-7989. The pricing file must be verified to determine coverage and reimbursement amounts.

The following drugs can be injected subcutaneously, intramuscularly, or intravenously.


J0702 INJECTION, BETAMETHASONE ACETATE AND BETAMETHASONE SODIUM PHOSPHATE, PER 3 MG NO



J CODE Procedure list


Abraxane Paclitaxel J9264
Factrel Vial w/ Diluent Gonadorel Hydrochloride J1620
Actemra Tocilizumab J3262
Faslodex Fulvestrant J9395
Actimmune Interferon gamma 1B J9216
Flebogamma Immune Globulin J1572
Aldurazyme Laronidase J1931
Flolan Epoprostenol J1325
Alferon N Interferon Alfa-N3 J9215
Gamma globulin, intramuscular, 1cc Immune Globulin J1460
Alimta Pemetrexed Disodium J9305
Gamma globulin, intramuscular, over 10cc Immune Globulin J1560
Aralast Alpha 1 proteinase J0256
Gammagard S/D, Gammargard Liq Immune Globulin J1569
Aranesp Darbopoietin J0881, J0882
Gammaplex Immune globulin C9270
Avastin Bevacizumab J9035, C9257
Gammar-P.I.V. Immune Globulin J1566
Avonex Interferon beta 1-a J1826, Q3025, Q3026
Gamunex Immune Globulin J1561 Belimumab Benlysta Q2044
Genotropin Cartridge Somatotropin J2941
Betaseron Vial Interferon beta 1-b J1830
Genotropin Miniquick Somatotropin J2941
Botox Botulinum toxin Type A J0585
Herceptin Trastuzumab J9355
Campath Alemtuzumab J9010
Hizentra Immune Globulin J1559
Carimune NF Immune Globulin J1566
Humatrope Cartridge Somatotropin J2941
Ceredase Alglucerase J0205
Humatrope Vial Somatotropin J2941
Cerezyme Imiglucerase J1786
Humira Pen Kit Adalimumab J0135
Cimzia Kit Certolizumab pegol J0718
Humira Syringe Adalimumab J0135
Copaxone Glatiramer Acetate J1595
Hyalgan Hyaluronate J7321
Dysport Abobotulinum Toxin A J0586
Immune Globulin Immune Globulin J1566 J1559, J1599, 90281, 90283
Eloxatin Oxaliplatin J9263
Increlex Mecasermin J2170
Enbrel Kit Etanercept J1438
Infergen Interferon Alfacon-1 J9212
Epogen or Procrit Erythropoietin J0885, J0886, Q4081
Infergen Vial Interferon Alfacon-1 J9212
Erbitux Cetuximab J9055
Intron A Inj Pen Interferon alfa-2b J9214
Euflexxa Hyaluronate J7323
Kineret Syr Anakinra J3490
Extavia Interferon beta-1b J1830
Leukine Sargramostim; GMCSF J2820
Fabrazyme Agalsidase Beta J0180
Lucentis Ranibizumab J2778
Lumizyme Alglucosidase Alfa C9257, C9277
Prokine Sargramostim J2820
Macugen PFS Pegaptanib J2503
Prolastin Alpha 1 proteinase J0256
Myobloc Botulinum toxin Type A J0587
Proleukin Aldesleukin, IL-2 J9015
Myozyme Alglucosidase Alfa J0220
Rebif Syringe Interferon beta 1-a Q3025, Q3026, J1826, J1830
Naglazyme Galsulfase J1458 Remicade Infliximab J1745
Neulasta 6mg/0.6ml PFS Pegfilgrastim J2505
Remodulin Treprostinil J3285
Neupogen Filgrastim; G-CSF J1440, J1441 Rituxan Rituximab J9310
Nordiflex Somatropin J2941
Rocephin for lyme disease Ceftriaxone Sodium J0696
Norditropin Somatropin J2941
Saizen Injection Somatotropin J2941
Norditropin CRTG Somatropin J2941
SCig Immune globulin 90284
Novantrone Mitoxantrone J9293
SCIg Immune Globulin Subcutaneous [Human] 90284
NuSpan Somatropin J2941
Serostim Vial Somatropin J2941
Nutropin AQ Somatropin J2941
Somatrem Somatrem J2940
Nutropin AQ Pen Cartridge Somatropin J2941
Somatropin Somatropin J2941
Nutropin AQ Vial Somatropin J2941
Stelara Ustekinumab J3357
Nutropin Depot Somatropin J2941
Supartz Hyaluronic acid J7321
Nutropin Vial Somatropin J2941
Synagis Palivizumab 90378
Octagam Immune Globulin J1568
Synvisc Hyaluronate J7325
Omnitrope Somatropin J2941
Synvisc One Hyaluronate J7325
Orencia Abatacept J0129
Tev-Tropin Somatropin J2941
Orthovisc Hyaluronate J7324
Tyvaso TREPROSTINIL J7686
Panglobulin Immune Globulin J1563
Vectibix Panitumumab J9303
Pegasys Vial Peginteferon Alfa 2a S0145
Velcade Bortezomib J9041
Peg-Intron RD Pen Kit Peginteferon Alfa 2a S0148
Veletri Epoprostenol J1325
Polygam S/D Immune Globulin J1563
Ventavis Lloprost Q4074
Prialt Ziconotide J2278
Vidaza Azacitidine J9025
Privigen Immune Globulin (Human) IV Soln J1459
Vpriv Velaglucerase alfa J3385
Xeomin IncobotulinumtoxinA Q2040
Xiaflex Collagenase, clostridium histolyticum J0775
Xolair Omalizumab J2357
Zemaira Alpha 1 proteinase J0256
Zobtrive Somatropin J2941

Immune Globulin Intravenous J CODES

J1459 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG

J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG

J1557 INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG

J1561 INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E.G., LIQUID), 500 MG

J1566 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G., POWDER), NOT OTHERWISE SPECIFIED, 500 MG

J1568 INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG

J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E.G., LIQUID), 500 MG

J1572 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG

J1599 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG

J0850 INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL

Why is UnitedHealthcare enforcing the NDC on professional drug claims?

A. We are enforcing this requirement as part of our effort to reduce overall costs to the health care system. NDCs are the industry standard identifier for drugs and provide full transparency to the medication administered. They accurately identify the manufacturer, drug name, dosage, strength, package size and quantity

What drug codes require the NDC to be submitted on professional claims effective Jan. 1, 2017?

A. The following drug codes are required:

** J codes, including miscellaneous and unlisted drug codes

** Drug-related CPT codes, including miscellaneous and unlisted drug codes, immunizations, Synagis, and Immune globulin

** Drug-related Q codes, including miscellaneous and unlisted drug codes, Contrast

** Drug-related S codes including Testopel

** Drug-related A codes, including miscellaneous and unlisted drug codes, and adiopharmaceuticals

The NDC will not be enforced for G codes and P codes



 Where is the NDC located?

A. The NDC is found on the prescription drug label of the drug container (e.g. vial, bottle or tube). The NDC is a universal number that identifies a drug or related drug item. The NDC number consists of 11 digits with hyphens separating the number into three segments in a 5-4-2 format. The first five digits identify the manufacturer of the drug and are assigned by the FDA. The remaining digits are assigned by the manufacturer and identify the specific product and package size.

Sometimes the NDC on the label does not include 11 digits. If this occurs, it will be necessary to add a leading zero to the appropriate section to create a 5-4-2 configuration (i.e.66733-0948-23 in the following sample). A valid NDC without spaces or hyphens should be placed on the medical claim. The NDC submitted must be the actual valid NDC number on the container from which the medication was administered.



NDC Unit of Measure (UOM)

UOM Description General Guidelines

F2 International unit International units will mainly be used when billing for Factor VIII-Antihemophilic Factors

GR Gram Grams are usually used when an ointment, cream, inhaler, or bulk powder in a jar are dispensed. This unit of measure will primarily be used in the retail pharmacy setting and not for physician-administered drug billing.

ML Milliliter If a drug is supplied in a vial in liquid form, bill in millimeters.

UN Unit If a drug is supplied in a vial in powder form, and must be reconstituted before administration, bill each vial (unit/each) used.



EXAMPLE NDC BILLING SCENARIO

To assist you with making the transition to billing with NDCs, we will be providing some example scenarios based on inquiries we are receiving from providers. This month’s scenario features a high-volume J code.

What was administered?

In our sample scenario, a patient receives 3 mg betamethasone acetate and betamethasone phosphate in the physician’s office. Code J0704 - injection, betamethasone sodium phosphate, per 4mg was deleted effective Dec. 31, 2010. Code J0702 - CELESTONE®  SOLUSPAN®  Injectable  Suspension is a sterile aqueous suspension containing 3 mg per milliliter betamethasone, as betamethasone sodium phosphate, and 3 mg per milliliter betamethasone acetate. Since this is the drug that was administered, then code J0702 is appropriate.


What’s on the package label?

Here are some examples of NDC information that you may see when you are preparing to bill with HCPCS code J0702 betamethasone acetate and betamethasone phosphate, per 3 mg:

• 00517-0720-01 6MG/ML SUSP Unit of Measure 5ML

• 54868-0206-00 6MG/ML SUSP Unit of Measure 5ML

• 58016-9191-01 6MG/ML SUSP Unit of Measure 5ML



What to include on the claim:

The initial dosage of CELESTONE SOLUSPAN Injectable Suspension may vary from 0.25 to 9.0 mg per day depending on the specific disease entity being treated. For the patient in our sample scenario,  you will use the NDC on the package label (e.g., NDC is 00517-0720-01, which is CELESTONE SOLUSPAN 6mg/ml in suspension form). There are 5 milliliters (ML) per vial. You will bill J0702 (betamethasone acetate and betamethasone phosphate, per 3 mg) with the NDC unit of measure as ML, and NDC units as 0.5 milliliters (ML0.5) for one 3mg dose.

Insufficient Documentation - 80% of Total Errors

Reasons for errors:

* Billed is CPT J1030 and 20610 - Methylprednisolone 40 MG injection. Missing order and documentation of Methylprednisolone 40 MG injection was administered. Received a partially illegible office visit note that list B-12 as the injection, and office visit notes.


INJECTION SUPPLY

* Injected supply billed with HCPCS “J” codes

* Do NOT bill for the local anesthetic (lidocaine, etc.)

* J1020-30 methylprednisolone acetate (Depo-Medrol)

* J1094 dexamethasone acetate (Decadron LA)

* J1100 dexamethasone sodium phosphate

* J3301-3 triamcinolone (Kenalog)

* Code based upon total mg applied on date of service; even if applied over multiple sites

* Use applicable modifiers to reflect separate sites

* LT, RT, -59 Modifier

What information do I need to have ready before converting HCPCS/CPT units to NDC units ?

Before you can fill out the claim to bill for a drug, you will need to know the following information:

* Amount of drug to be billed

* HCPCS/CPT code


* HCPCS/CPT code description

* Number of HCPCS/CPT units

* NDC (11-digit billing format)

* NDC description

* NDC unit of measure

Consider the following example for Ciprofloxacin IV 1200 MG (1 day supply):

Amount of drug to be billed:

1200 MG

HCPCS/CPT code:

J0744

HCPCS/CPT code description:

Ciprofloxacin for intravenous infusion, 200 MG

Number of HCPCS/CPT units

6

NDC (11-digit billing format):

00409-4765-86

NDC description:

Ciprofloxacin IV SOLN 200 MG/20 ML

NDC unit of measure

ML


Most Used J Code CPT codes and covered ICD codes


B. The following well-established drugs will be allowed for cancer therapy and for other therapy as indicated. (C00-D49.9, or E34.0)

1. Bleomycin sulfate, 15 units (Blenoxane) (J9040)
Warts B07.0, B07.8, B07.9
2. Carboplatin 50 mg, (Paraplatin) (J9045)
3. Carmustine 100 mg, (BCNU, BiCNU) (J9050)
4. Cisplatin (Platinol) powder or solution, per 10 mg (J9060)
5. Cyclophosphamide (Cytoxan) 100 mg (J9070)
See section F for non-oncological uses.
6. Cytarabine 100 mg. (J9100)
7. Dacarbazine (DTIC) 100 mg (J9130)
8. Dactinomycin 0.5mg (actinomycin-D, Cosmegen) (J9120)
9. Doxorubicin Hydrochloride 10 mg (Adriamycin) (J9000)
10. Diethylstilbestrol Diphosphate, 250 mg (J9165)
11. Etoposide (VePesid) 10 mg (J9181) Etopside phosphate (Etopophos)
12. Floxuridine (FUDR) 500 mg (J9200)
13. Fluorouracil (5FU, Adrucil) 500 mg (J9190)
glaucoma for patients at high risk for filtering surgery failure. (H40.1111, H40.1112, H40.1113, H40.1114, H40.1121, H40.1122, H40.1123, H40.1124, H40.1131, H40.1132, H40.1133, H40.1134, H40.1191, H40.1192, H40.1193, H40.1194, H40.1211- H40.1214, H40.1221- H40.1224, H40.1231-H40.1234, H40.1311- H40.1314, H40.1321- H40.1324, H40.1331- H40.1334, H40.1411-H40.1414, H40.1421- H40.1424, H40.1431-H40.1434, H40.151- H40.153, H40.20X1-H40.20X4, H40.211- H40.213, H40.2211-H40.2214, H40.2221- H40.2224, H40.2231-H40.2234, H40.231-H40.233, H40.241- H40.243, H40.31X1- H40.31X4, H40.32X1- H40.32X4, H40.33X1- H40.33X4, H40.41X1-H40.41X4, H40.42X1-.H40.42X4, H40.43X1- H40.43X4, H40.51X1- H40.51X4, H40.52X1- H40.52X4, H40.53X1- H40.53X4, H40.61X1-H40.61X4, H40.62X1-H40.62X4, H40.63X1-H40.63X4, H40.811-H40.813, H40.821-H40.823, H40.829, H40.831-H40.833, H40.839, H40.89, H40.9)
Verruca - (A63.0, B07.0,B07.8,B07.9)
14. Ifosfamide 1 gram (J9208)
15. Leucovorin calcium, per 50 mg (J0640)
16. Levoleucovorin calcium, 0.5mg (J0641)
17. Mechlorethamine hydrochloride (Nitrogen Mustard), 10 mg (J9230)
18. Mesna 200 mg (Urothelial Protectant used in combination with cyclophosphamide or Ifosfamide) (J9209) (N30.90, N30.91)
19. Methotrexate Sodium; (MTX, Folex) 5 mg (J9250), Methotrexate Sodium; (MTX, Folex) 50 mg (J9260) See section F for non-oncological uses.
20. Plicamycin 2.5mg (Mithracin) (J9270)
21. Mitomycin (Mutomycin) 5 mg (J9280) Use/See J7315 for ophthalmic use
22. Thiotepa 15 mg (J9340)
23. Vinblastine sulfate (Velban) 1 mg (J9360)
24. Vincristine (Oncovin) 1 mg (J9370), (D59.1, D69.59).
The following have been added:
25. BCG (Intravesical), per installation (J9031)
26. Cladribine Chlorodexyadenoside (2-CDA) (Leustatin) 1 mg (J9065)
27. Daunorubicin, 10 mg (J9150)
28. Daunorubicin citrate, liposomal formulation, (DaunoXome) 10 mg (J9151)
29. Doxorubicin Hydrochloride, liposomal, Doxil, 10 mg Not otherwise specified (Q2050 ) and Doxorubicin Hydrochloride, liposomal imported Lipodox, 10 mg (Q2049)
30. Docetaxel (Taxotere) 1mg (J9171)
31. Epirubicin Hydrochloride (Ellence) 2 mg (J9178)
32. Fludarabine Phosphate (Fludara) 50 mg (J9185)(Z94.84)
33. Fulvestrant (Faslodex™) 25mg (J9395)
34. Gemcitabine Hydrochloride (Gemzar) 200 mg (J9201)
35. Idarubicin Hydrochloride (Idamycin) 5mg (J9211)
36. Interferon, alpha-2B, recombinant, 1 million units (Intron A) (J9214) (A63.0, B07.0, B07.8, B07.9, B18.1, B18.2)
37. Irinotecan (Camptosar) 20 mg (J9206)
38. Melphalan Hydrochloride (Alkeran) (J9245) 50 mg (Z48.290, Z94.81, Z94.84) Please note, Evomela indications are listed in Section C.
39. Mitoxantrone (Novantrone) (J9293) (G35, Multiple Sclerosis)
40. Oxaliplatin (Eloxatin™) 0.5 mg (J9263)
41. Paclitaxel (Taxol) 30mg ( J9267)
42. Pemetrexed (Alimta?) 10 mg (J9305)
43. Streptozocin (Zanosar) 1 gram (J9320)
44. Topotecan (Hycamtin) 0.1 mg (J9351)
45. Valrubicin intravesical (Valstar) 200mg (J9357)
46. Vinorelbine tartrate (Navelbine) 10 mg (J9390)
47. Aldesleukin per single use vial (Proleukin) (Interleukin-2) (J9015)
48. Arsenic Trioxide (Trisenox) 1mg (J9017)
49 Interferon, Alfa-N3 (Human Leukocyte Derived) 250,000 IU (Alferon N)(J9215) (A63.0, B07.0, B07.8, B07.9)
50. Octreotide, Depot Form for Intramuscular Injection 1 mg (Sandostatin LAR Depot) (J2353) (E22.0, E34.4, K52.89, K55.21, K63.2)
51. Cytarabine Liposome (Depocyt) 10 mg (J9098)
52. Pentostatin (Nipent) 10 mg (J9268)
53. Teniposide (Vumon) 50 mg (Q2017)

C. The following drugs are approved per FDA or NCCN guidelines for the specific indications listed:

1. ado-trastuzumab emtansine, 1mg (KADCYLA™)(J9354) 

Patients must have a positive 2+ HER 2 and metastatic disease, or a positive 3+ HER 2 test or a positive fish test for all indications below:

Is covered as a single agent, for the treatment of patients with HER2-positive, metastatic breast cancer who previously received trastuzumab and a taxane, separately or in combination. Patients should have either:

Received prior therapy for metastatic disease, or developed disease recurrence during or within six months of completing adjuvant therapy (C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922).
Effective 02/22/2013-FDA approval date.

Or per NCCN: Single-agent therapy for recurrent or metastatic human epidermal growth factor receptor 2-positive disease

•with symptomatic visceral disease or visceral crisis

•that is hormone receptor-negative or hormone receptor-positive and endocrine therapy refractory (C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922).

2. Asparaginase, (erwinaze), 1,000 units (J9019), Asparaginase, not otherwise specified 10,000 units (J9020)

C43.0, C43.11, C43.12, C43.21, C43.22, C43.31, C43.39, C43.4 C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8 Malignant melanoma of skin
C81.90-C81.99 Hodgkin lymphoma
C82.00-C82.99 lymphoma
C82.50-C82.69 Diffuse or cutaneous follicle center lymphoma
C82.80-C82.89 Other types of follicular lymphoma
C83.00-C83.09 Small cell B-cell lymphoma
C83.10-C83.19 Mantle cell lymphoma
C83.30-C83.39 Diffuse large B-cell lymphoma
C83.50-C83.59 Lymphoblastic (diffuse) lymphoma
C83.70-C83.79 Burkitt lymphoma
C83.80-C83.89 Other non-follicular lymphoma
C83.90-C83.99 Non-follicular (diffuse) lymphoma
C84.01-C84.09 Mycosis fungoides
C84.11-C84.19 Sezary’s disease
C84.40- C84.49 Peripheral T-cell lymphoma
C84.60- C84.79 Anaplastic large cell lymphoma
C84.90- C84.99 Mature T/NK-cell lymphomas
C84.A0- C84.A9 Cutaneous T-cell lymphoma
C84.Z0- C84.Z9 Other mature T/NK-cell lymphomas
C85.10-C85.19 Unspecified B-cell lymphoma
C85.20- C85.29 Mediastinal (thymic) large B-cell lymphoma
C85.80- C85.89 Other specified types of non-Hodgkin lymphoma
C85.90- C85.99 Non-Hodgkin lymphoma
C86.0-C86.4 Other specified types of T/NK-cell lymphoma
C86.5 Angioimmunoblastic T-cell lymphoma
C86.6 Primary cutaneous CD30-positive T-cell proliferations
C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated
C91.00-C91.02 Acute lymphoblastic leukemia
C91.10-C91.12 Chronic lymphocytic leukemia of B-cell type
C91.40-C91.42 Hairy cell leukemia
C92.01, C92.02 Acute myeloblastic leukemia
C92.10, C92.12 Chronic myeloid leukemia
C92.20-C92.22 Atypical chronic myeloid leukemia
C92.30-C92.32 Myeloid sarcoma
C92.40-C92.42 Acute promyelocytic leukemia
C92.50-C92.52 Acute myelomonocytic leukemia
C92.60-C92.62 Acute myeloid leukemia with 11q23-abnormality
C92.90-C92.92 Myeloid leukemia
C92.A0-C92.A2 Acute myeloid leukemia with multilineage dysplasia
C92.Z0-C92.Z2 Other myeloid leukemia
C93.00-C93.02 Acute monoblastic/monocytic leukemia
C93.10-C93.12 Chronic myelomonocytic leukemia
C93.30-C93.32 Juvenile myelomonocytic leukemia
C93.90-C93.92 Monocytic leukemia, unspecified
C93.Z0-C93.Z2 Other monocytic leukemia
C94.00-C94.02 Acute erythroid leukemia
C94.20-C94.22 Acute megakaryoblastic leukemia
C94.30-C94.32 Mast cell leukemia
C94.80-C94.82 Other specified leukemias
C95.00-C95.02 Acute leukemia of unspecified cell type
C96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis
C96.2 Malignant mast cell tumor
C96.4 Sarcoma of dendritic cells (accessory cells)
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
C96.A Histiocytic sarcoma
C96.Z Other specified malignant neoplasms of lymphoid hematopoietic and related tissue

3. Azacitidine (Vidaza™) (J9025), 1 mg 

C92.00, C92.01, C92.02 Acute myeloblastic leukemia
C92.10, C92.12 Chronic myeloid leukemia, BCR/ABL-positive
C92.40-C92.42 Acute promyelocytic leukemia,
C92.50-C92.52 Acute myelomonocytic leukemia,
C92.60-C92.62 Acute myeloid leukemia with 11q23-abnormality
C92.A0-C92.A2 Acute myeloid leukemia with multilineage dysplasia
C93.00-C93.02 Acute monoblastic/monocytic leukemia
C93.10, C93.12 Chronic myelomonocytic leukemia
C94.00-C94.02 Acute erythroid leukemias
C94.20-C94.22 Acute megakaryoblsic leukemia
D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9 Refractory anemia and myelodysplastic syndrome, unspecified.
D46.A, D46.B Refractory cytopenia with multilineage dysplasia
D46.C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.Z Other myelodysplastic syndromes
D47.1 Chronic myeloproliferative disease

4. Belinostat (Beleodaq) (J9032) 10mg, is indicated for the treatment of relapsed or refractory peripheral T-cell lymphoma (PTCL) (C84.40-C84.49, C84.60-C84.69,

C84.70-C84.79, C86.2, C86.5, Z85.72 ). Effective 07/03/2014-FDA approval date.

Or per NCCN:
C84.00-C84.09 Mycosis Fungoides/Sezary’s
C86.6 T-cell lymphoproliferative disorders
C91.50, C91.52 T-cell leukemia/lymphoma

5. Bendamustine hydrochloride (Treanda™)(Bendeka), 1 mg J9033 

C81.00-C81.99 Hodgkin lymphoma
C82.00-C82.99, C83.00-C83.99 Lymphoma
C84.01-C84.09 Mycosis fungoides
C84.11-C84.19 Sezary’s disease
C84.40- C84.49 Peripheral T-cell lymphoma
C84.60- C84.79 Anaplastic large cell lymphoma
C84.90- C84.99 Mature T/NK-cell lymphomas
C84.A0- C84.A9 Cutaneous T-cell lymphoma
C84.Z0- C84.Z9 Other mature T/NK-cell lymphomas
C85.10-C85.19 Unspecified B-cell lymphoma
C85.20- C85.29 Mediastinal (thymic) large B-cell lymphoma
C85.80- C85.89 Other specified types of non-Hodgkin lymphoma
C85.90- C85.99 Non-Hodgkin lymphoma
C86.0-C86.4 Other specified types of T/NK-cell lymphoma
C86.5 Angioimmunoblastic T-cell lymphoma
C86.6 Primary cutaneous CD30-positive T-cell proliferations
C88.0 Waldenstrom macroglobulinemia
C88.2-C88.4 B-cell lymphoma
C88.8-C88.9 Immunoproliferative disease
C90.00- C90.02 Multiple myeloma
C90.10 Plasma cell leukemia
C90.12 Plasma cell leukemia
C90.20 Plasmacytoma
C90.22 Plasmacytoma
C90.30 Plasmacytoma
C90.32 Plasmacytoma
C91.10-C91.12 Chronic lymphocytic leukemia of B-cell type
C91.40-C91.42 Hairy cell leukemia
C96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis
C96.2 Malignant mast cell tumor
C96.4 Sarcoma of dendritic cells (accessory cells)
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue
C96.A Histiocytic sarcoma
C96.Z Other specified malignant neoplasms of lymphoid hematopoietic and related tissue
C91.50, C91.60, C91.A0, C91.Z0, C91.32, C91.52, C91.62, C91.A2, C91.Z2 Adult T- cell Leukemia/lymphoma

6. Bevacizumab (Avastin™) (J9035), 10 mg 

C17.0, C17.1, C17.2, C17.8, C17.9, C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C21.0, C21.1, C21.2, C21.8 Malignant neoplasm: small intestine, appendix, colon, rectum, anus
C33 Malignant neoplasm of trachea
C34.01, C34.02, C34.11, C34.12, C34.2, C34.31, C34.32, C34.81, C34.82, C34.91, C34.92 Malignant neoplasm, bronchus, lobe
C38.4, C45.0 Malignant neoplasm, pleura and mesothelioma of pleura
C45.1 Mesothelioma of peritoneum
C47.0, C47.11, C47.12, C47.21, C47.22
C47.3, C47.4, C47.5, C47.6, C47.8, C47.9 Malignant neoplasm of peripheral nerves, autonomic nervous system
C48.0, C48.1, C48.8 Malignant neoplasm of retroperitoneum, peritoneum
C49.0, C49.11, C49.12, C49.21, C49.22, C49.3-C49.6, C49.8 Malignant neoplasm of connective and soft tissue
C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922 Malignant neoplasm of breast
C53.0, C53.1, C53.8, C53.9, C54.9, C56.1, C56.2, C57.01, C57.02, C57.11, C57.12, C57.21, C57.22, C57.3 Malignant neoplasm of cervix, ovary, other female genital organs
C54.1, C54.2, C54.3, C54.8 Malignant neoplasm of corpus uteri
C64.1, C64.2, C65.1, C65.2, C64.9, C65.9 Malignant neoplasm of kidney, renal pelvis
C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9 Malignant neoplasm of brain
C78.01-78.02 Secondary malignant neoplasm lung
C78.6-C78.7 Secondary malignant neoplasms retroperitoneum/peritoneum and liver/bile duct.
D43.0-D43.1 Neoplasm, uncertain behavior of brain
D43.4 Neoplasm, uncertain behavior of spinal cord.

7. Blinatumomab (BLINCYTO™) (J9039), 1mcg 

For the treatment of Philadelphia chromosome-negative relapsed or refractory B-
cell precursor acute lymphoblastic leukemia (ALL) (C91.02). Effective
12/03/2014-FDA approval date.

Or per NCCN: Philadelphia chromosome positive disease refractory to tyrosine
kinase inhibitor therapy (C91.02).

8. Bortezomib (Velcade™ (J9041), 0.1mg 

C82.53 Diffuse follicle center lymphoma
C83.00-C83.09 Small cell B-cell lymphoma
C83.50-C83.59 Lymphoblastic (diffuse) lymphoma
C83.10-C83.19 Mantle cell lymphoma
C84.40- C84.49 Peripheral T-cell lymphoma
C84.60- C84.79 Anaplastic large cell lymphoma
C84.90- C84.99 Mature T/NK-cell lymphomas
C84.A0- C84.A9 Cutaneous T-cell lymphoma
C84.Z0- C84.Z9 Other mature T/NK-cell lymphomas
C85.10-C85.19 Unspecified B-cell lymphoma
C85.20- C85.29 Mediastinal (thymic) large B-cell lymphoma
C85.80- C85.89 Other specified types of non-Hodgkin lymphoma
C85.90- C85.99 Non-Hodgkin lymphoma
C86.0-C86.4 Other specified types of T/NK-cell lymphoma
C88.0 Waldenstrom macroglobulinemia
C88.2 Heavy chain disease
C88.3 Immunoproliferative small intestinal disease
C88.8 Other malignant immunoproliferative diseases
C88.9 Malignant immunoproliferative disease, unspecified
C90.00-C90.02 Multiple myeloma
C90.10, C90.12 Plasma cell leukemia
C90.20-C90.22 Plastmacytomas
C90.30-C90.32 Plastmacytomas
D47.Z2 Castleman’s disease
D36.0 Benign neoplasm lymph nodes
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D36.0 Benign neoplasm lymph nodes
E85.9 Amyloidosis
R59.0, R59.1, R59.9 Enlarged lymph nodes

9. Brentuximab vedotin, (ADCETRIS™) (J9042) 1mg FDA approved 08/19/2011 for: 

- The treatment of patients with Hodgkin lymphoma after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not ASCT candidates (C81.00-C81.99)
- The treatment of patients with systemic anaplastic large cell lymphoma (excluding cutaneous ALCL) after failure of at least one prior multi-agent chemotherapy regimen and for CD 30+ peripheral T-cell lymphoma (C84.60-C84.69, C84.70-C84.79, C84.40-C84.49)

Or Hodgkin lymphoma at high risk of relapse or progression as post aHSCT consolidation (Z94.81, Z94.84). Effective 08/17/2015.

Or per NCCN:
C83.01-C83.09 B cell lymphoma
C83.81-C83.89 Non follicular lymphoma
C84.01-C84.09 Mycosis fungoides
C84.11-C84.19 Sezary’s disease
C84.41-C84.49 Peripheral T cell lymphoma
C84.61-C84.69 Anaplastic large cell lymphoma
C84.71-C84.79 Anaplastic large cell lymphoma
C86.5-C86.6 T cell lymphoma

10. Cabazitaxel (Jevtana®) (J9043) 1 mg, effective 07/17/10 FDA approval date
Microtubular inhibitor indicated in combination with prednisone for treatment of hormone refractory metastatic prostate cancer (C61) previously treated with a docetaxel containing regimen.

Or per NCCN: Used in combination with prednisone following disease progression for castration-recurrent metastatic disease previously treated with a docetaxel-based regimen (C61).

11. Carfilzomib 1 mg (KYPROLIS™) (J9047)

KYPROLIS is a proteasome inhibitor indicated for the treatment of patients with multiple myeloma who have received at least two prior therapies including
bortezomib and an immunomodulatory agent and have demonstrated disease progression on or within 60 days of completion of the last therapy (C90.00, C90.01, C90.02). Effective 07/20/12-FDA approval date.

Or in combination with dexamethasone or with lenalidomide plus dexamethasone for the treatment of patients with relapsed or refractory multiple myeloma who have received one to three lines of therapy. Effective 01/21/2016-FDA approval date (C90.00, C90.01, C90.02).

Or as a single agent for the treatment of patients with relapsed or refractory multiple myeloma who have received one or more lines of therapy. Effective 01/21/2016-FDA approval date (C90.00, C90.01, C90.02).

Or per NCCN: Used in combination with lenalidomide and dexamethasone for transplant candidates with progressive solitary plasmacytoma or smoldering myeloma (asymptomatic) that has progressed to active (symptomatic) myeloma as primary chemotherapy (C88.2, C88.3, C88.8, C90.00, C90.01, C90.02, C90.10, C90.12, C90.20, C90.22, C90.30, C90.32).

As preferred therapy for previously treated myeloma on/off clinical trials for disease relapse, progressive disease or refractory disease (C88.2, C88.3, C88.8, C90.00, C90.02, C90.10, C90.12, C90.20, C90.22, C90.30, C90.32).

Waldenstrom’s/Lymphoplasmacytic Lymphoma (C83.01-C83.09, C83.81-C83.89, C86.5, C86.6, C88.0).

12. Cetuximab (Erbitux™) (J9055) 10 mg 

C00.0, C00.1, C00.3, C00.4, C00.6, C00.8, , C01, C02.0-C02.4, C02.8, C02.9, C03.0, C03.1, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C05.2, C05.8, C06.0, C06.1, C06.2, C06.89 Malignant neoplasm of lip, tongue, gum, mouth, palate & other parts of the mouth
C07, C08.0, C08.1, C08.9 Malignant neoplasm of parotid gland, other specified salivary glands
C09.0, C09.1, C09.8, C09.9 Malignant neoplasm of tonsil
C10.0- C10.8, C11.0-C11.3. C11.8, C12, C13.0, C13.1, C13.2, C13.8. Malignant neoplasm of : oropharynx , nasopharynx, pyriform sinus, hypopharynx
C14. 2, C14.8 Malignant neoplasm of other defined sites in lip, oral cavity and pharynx
C17.0-C17.2, C17.8, C18.0-C18.8, C19, C20, C21.0, C21.1, C21.2, C21.8 Malignant neoplasm: small intestine, appendix, colon, rectum, anus
C30.0, C30.1, C31.0, C31.1, C31.2, C31.3, C31.8 Malignant neoplasm of accessory sinuses
C32.0-C32.3, C32.8 Malignant neoplasm of larynx
C33, C34.01, C34.02, C34.11, C34.12, C34.2, C34.31, C34.32, C34.81, C34.82, C34.91, C34.92 Malignant neoplasm, bronchus, lobe
C44.02, C44.09, C44.122, C44.129, C44.222
C44.229, C44.321, C44.329, C44.42, C44.520, C44.521, C44.529, C44.622, C44.629, C44.722, C44.729, C44.82 Squamous cell carcinoma
C60.0, C60.1, C60.2, C60.8, C63.7, C63.8 Malignant neoplasm, penis
C76.0 Malignant neoplasm of head, face and neck
C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C78.01, C78.02, C78.6, C78.7, C79.89 Secondary malignant neoplasm, multiple sites
D37.01, D37.02, D37.04, D37.05, D37.09, D38.0, D38.5 Neoplasm of uncertain behavior, lip, tongue, salivary glands, pharynx, oral cavity, larynx, other,
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
Z85.828 Personal history of other malignant neoplasm of skin

Is indicated for the treatment of patients with recurrent or metastatic Head and Neck Squamous Cell Carcinoma (HNSCC) with disease progression on or after platinum-containing chemotherapy. C00.0-C00.6, C00.8, C00.9, C01, C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C06.0, C06.2, C06.80, C06.89, C06.9, C09.0, C09.1, C09.8, C09.9, C10.3,C11.0-C11.3, C11.8, C11.9, C12, C13.0-C13.2, C13.8, C13.9, C14.0, C14.2, C14.8, C31.0, C31.1,C32.0-C32.3, C32.8, C32.9, C44.00, C44.02, C44.09, C44.121, C44.122, C44.129, C44.221, C44.222, C44.229, C44.320, C44.321, C44.329, C44.42, C44.82, C44.89, C76.0, C77.0, D37.01, D37.02, D37.05, D37.09, D38.0, D38.5, D38.6, Z85.21, Z85.22, Z85.810, Z85.818, Z85.819, Z85.828. Effective date 08/01/2016, FDA approval

13. Decitabine (Dacogen) (J0894)

C92.00-C92.02 Acute myeloblastic leukemia
C92.10-C92.12 Chronic myeloid leukemia, BCR/ABL-positive
C92.40- C92.42 Acute promyelocytic leukemia
C92.50-C92.52 Acute myelomonocytic leukemia
C92.60-C92.62 Acute myeloid leukemia with 11q23-abnormality
C92.A0- C92.A2 Acute myeloid leukemia with multilineage dysplasia
C93.00, C93.01, C93.02, C93.10, C94.00, C94.01, C94.02, C94.20, C94.21, C94.22 Acute leukemias and Chronic myelomonocytic leukemia
D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9, D46.A, D46B, D46.C, D46.Z Myelodysplastic syndromes
D47.1 Chronic myeloproliferative disease

14. Eribulin mesylate (Halaven) (J9179), 0.1mg FDA Approved 11/15/2010

For the treatment of patients with metastatic breast cancer who have previously received at least two chemotherapeutic regimens for the treatment of metastatic disease. Prior therapy should have included anthracycline and a taxane in either the adjuvant or metastatic setting (C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922, C50.919).

For the treatment of patients with metastatic breast cancer who have previously received at least two chemotherapeutic regimens for the treatment of metastatic disease. Prior therapy should have included anthracycline and a taxane in either the adjuvant or metastatic setting for Soft Tissue Sarcoma-Angiosarcoma.
Also indicated for the treatment of patients with unresectable or metastatic liposarcoma who have received a prior anthracycline-containing regimen. (C48.0-C48.2, C49.0, C49.10-C49.12, C49.20-C49.22, C49.3-C49.6, C49.8, C49.9) Effective FDA approval 01/28/2016

Or per NCCN:
C45.1, C48.0, C48.1, C48.8 Malignant neoplasm of peritoneum and retroperitoneum
C47.0, C47.3, C47.4, C47.5, C47.8, C47.11, C47.12, C47.21, C47.22, C49.0, C49.11, C49.12, C49.21, C49.22, C49.3, C49.4, C49.5, C49.8 Malignant neoplasms of peripheral nerves, connective and soft tissue.

15. Ipilimumab (Yervoy™ 1mg, (J9228)
For the treatment of unresectable or metastatic melanoma
C43.0, C43.9, C43.11, C43.12, C43.21, C43.22, C43.31, C43.39, C43.4 C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8, C51.0-C51.2, C51.9, C60.0, C60.1, C60.9, C52 Malignant melanoma of skin
C79.31 Secondary malignant neoplasm of brain
Z85.820 Personal history of malignant melanoma of skin

16. Ixabepilone (Ixempra™), 1mg (J9207 )
C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922 Malignant neoplasm of breast

17. Melphalan hydrochloride (Evomela) (J9245)
Evomela indicated for high-dose conditioning treatment prior to hematopoietic progenitor (stem) cell transplantation in patients with multiple myeloma and the palliative treatment of patients with multiple myeloma for whom oral therapy is not appropriate (C90.00, C90.02, C90.10, C90.12, C90.20, C90.22, C90.30, C90.32). Effective 03/10/2016-FDA approval date.

18. Nelarabine (Aarron) (J9261) 50 mg

C83.50-C83.59 Lymphoblastic (diffuse) lymphoma
C91.00- C91.02 Acute lymphoblastic leukemia

19. Nivolumab (OPDIVO) (J9299), 1mg 
Covered for the treatment of patients with unresectable or metastatic melanoma and disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor. (C43.0, C43.11, C43.12, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8). Effective 12/22/2014-FDA approval date. (Z85.820, effective 10-01-2015)

Covered in combination with ipilimumab in patients with BRAF V600 wild-type melanoma. (C43.0, C43.11, C43.12, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8, C43.9). Effective 09/30/2015-FDA approval date. (Z85.820, effective 10-01-2015)

NCCN Information:

Non-Small Cell Lung Cancer (NSCLC): Preferred single agent (if not already given) as subsequent therapy for metastatic disease in patients with performance status 0-2: (1 for progression following a first-line cytotoxic regimen; 2A for further progression)
following progression on a first-line cytotoxic regimen

for further progression on other systemic therapy

with progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving nivolumab. (C33, C34.00-C34.02, C34.10-C34.12, C34.2, C34.30-C34.32, C34.80-C34.82, C34.90-C34.92, Z85.118). Effective 03/04/2015-FDA approval date.

Advanced renal cell carcinoma in patients who have received prior anti-angiogenic therapy. Effective 11/23/2015-FDA approval date. (C64.1, C64.2, C64.9, C65.1, C65.2, C65.9, Z85.528)

Metastatic or unresectable melanoma of vulva (C51.0-C51.8)-Effective 10/01/2015.

For the treatment of patients with classical Hodgkin lymphoma (cHL) that has relapsed or progressed after autologous hematopoietic stem cell transplantation (HSCT) and post-transplantation brentuximab vedotin (C81.10-C81.19, C81.20-C81.29, C81.30-C81.39, C81.40-C81.49, C81.72-C81.79, C81.90-C81.99). Effective 05/17/2016 -FDA approval date.

Or per NCCN:
Melanoma: Therapy for metastatic or unresectable disease as a single agent or in combination with ipilimumab as first-line therapy

second-line or subsequent therapy for disease progression for patients with performance status 0-2 if not previously used (C43.0, C43.11, C43.12, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8, C43.9, C69.90-C69.92, and C79.31).

20. Obinutuzumab (GAZYVA) (J9301) is a CD20-directed cytolytic antibody and is indicated, in combination with chlorambucil, for the treatment of patients with previously untreated chronic lymphocytic leukemia.(C91.10). Effective FDA approval date (11/01/2013); Small lymphocytic lymphoma C83.50-C83.59: effective 02/01/2015 . Indicated, in combination with chlorambucil, for the treatment of patients with previously untreated Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL). (C83.50-C83.59, C91.10, C91.12) Effective FDA 04/01/2015.

Obinutuzumab in combination with bendamustine followed by GAZYVA monotherapy, for the treatment of patients with follicular lymphoma (FL) who relapsed after, or are refractory to, a rituximab-containing regimen (C82.00-C82.09, C82.10-C82.19, C82.20-C82.29, C82.30-C82.39, C82.40-C82.49, C82.90-C82.99, C83.00-C83.09) Effective FDA approval date -02/26/2016.

21. Ofatumumab (Arzerra) 10 mg (J9302) 
Used in combination with chlorambucil for the treatment of previously untreated patients with Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) for whom fludarabine-based therapy is considered inappropriate (C83.50-C83.59, C91.10, C91.12). Effective 04/17/2014-date of FDA approval.

C83.10-C83.19 Mantle cell lymphoma
C83.30-C83.39 Diffuse large B-cell lymphoma
C83.70-C83.79 Burkitt lymphoma
C83.80-C83.99 Other non-follicular lymphoma
C84.60- C84.79 Anaplastic large cell lymphoma
C85.20-C85.29 Mediastinal (thymic) large B-cell lymphoma
C86.5 Angioimmunoblastic T-cell lymphoma

C86.6 Primary cutaneous CD30-positive T-cell proliferations
C88.4 Extranodal marginal zone B-cell lymphoma-MALT

Indicated as a single-agent or combination therapy with in rituximab-intolerant patients for previously treated disease that does not respond to primary therapy or for progressive or relapse disease: Waldenstrom’s Macroglobulinemia/Lymphoplasmacytic Lymphoma (C83.00-C83.09, C88.0, Z85.72, Z85.79) Effective FDA approval 04/17/2014.

22. Omacetaxine mepesuccinate, (SYNRIBO) 0.01 mg (J9262) is covered for the treatment of adult patients with chronic or accelerated phase chronic myeloid leukemia (CML) with resistance and/or intolerance to two or more tyrosine kinase inhibitors (TKI).
C92.10-C92.12 Chronic myeloid leukemia, BCR/ABL-positive

23. Paclitaxel protein-bound particles, 1 mg (Abraxane™) (J9264)
C25.0-C25.8 Malignant neoplasm of gallbladder bilary tract , pancreas
C33, C34.01, C34.02, C34.11, C34.12, C34.2, C34.31, C34.32, C34.81, C34.82, C34.91, C34.92 Malignant neoplasm, bronchus, lobe
C43.0, C43.10-C43.12, C43.20-C43.22, C43.30-C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8, C43.9, C79.31 Malignant melanomas
C45.1, C48.1, C48.8 Mesothelioma of peritoneum, retroperitoneum
C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922. Malignant neoplasm of breast
C56.1, C 56.2, C57.01, C57.02, C57.11, C57.12, C57.21, C57.22, C57.3 Malignant neoplasm of corpus uteri, ovary, other female genital organs
D03.39, D03.4, D03.51, D03.52, D03.59, D03.61, D03.62, D03.71, D03.72, D03.8, Melanomas

24. Panitumumab (Vectibix), 10 mg (J9303) 
Panitumumab (Vectibix™) is indicated for the treatment of metastatic colorectal carcinoma. Patient must not have K-RAS mutation. Panitumumab is a recombinant human monoclonal antibody. If the patient has disease progression on an Epidermal Growth Factor Receptor (EGFR) monoclonal antibody, it would not be appropriate to use this drug.
C17.0, C17.1, C17.2, C17.8 Malignant neoplasm duodenum, jejunum, ileum and overlapping sites of small intestine
C18.0-C18.8, C19, C20,
C21.0- C21.2, C21.8 Malignant neoplasm of colon, anus and anal canal
C78.01, C78.02, C78.6, C78.7 Secondary malignant neoplasms

25. Pembrolizumab (Keytruda) (J9271), 1mg is indicated for the treatment of patients with unresectable or metastatic melanoma (C43.0, C43.11, C43.12, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8) and disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor. Effective 09/04/2014 -FDA approval date.
Clarification of above FDA approval: First line therapy for unresectable or metastatic melanoma. Second line therapy for disease progression following ipilimumab.

Effective 12/18/2015-FDA approval date: First line treatment for patients with unresectable or metastatic melanoma, regardless of BRAF status.

Metastatic NSCLC whose tumors express PD-L1 as determined by an FDA-approved test and who have disease progression on or after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving KEYTRUDA (C33, C34.00-C34.02, C34.10-C34.12, C34.2, C34.30-C34.32, C34.80-C34.82, C34.90-C34.92). Effective 10/02/2015, FDA approval date.

Metastatic or unresectable melanoma of vulva (C51.0-C51.8)-Effective 10/01/2015.

Is indicated for the treatment of patients with recurrent or metastatic Head and Neck Squamous Cell Carcinoma (HNSCC) with disease progression on or after
platinum-containing chemotherapy. (C00.0-C00.6, C00.8, C00.9, C01, C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C06.0, C06.2, C06.80, C06.89, C06.9, C09.0, C09.1, C09.8, C09.9, C10.3,C11.0-C11.3, C11.8, C11.9, C12, C13.0-C13.2, C13.8, C13.9, C14.0, C14.2, C14.8, C31.0, C31.1,C32.0-C32.3, C32.8, C32.9, C44.00, C44.02, C44.09, C44.121, C44.122, C44.129, C44.221, C44.222, C44.229, C44.320, C44.321, C44.329, C44.42, C44.82, C44.89, C76.0, C77.0, D37.01, D37.02, D37.05, D37.09, D38.0, D38.5, D38.6, Z85.21, Z85.22, Z85.810, Z85.818, Z85.819, Z85.828)
Effective date 08/01/2016, FDA approval

Or per NCCN:
C43.0, C43.11, C43.12, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8, C43.9, C69.90-C69.92 Malignant melanomas and other melanoma
C79.31 Secondary malignant neoplasm of brain
Z85.820 Personal history of malignant melanoma of skin

26. Pegaspargase (Oncaspar) per single dose vial (J9266) 
(When patient has developed a hypersensitivity to native forms of L-asparaginase)

C82.51-C82.59 Lymphomas-diffuse
C84.90-C84.99 Mature T/NK cell lymphomas
C84.Z1-C84.Z9 Other mature T/NK cell lymphomas
C85.21-C85.26 Non-Hodgkin lymphoma, other specified types
C85.82-C85.89 Non-Hodgkin lymphoma, other specified types
C86.0-C86.4 Other T/NK cell lymphomas
C91.00-C91.02 Acute lymphoblastic leukemias

27. Pertuzumab, 1 mg (PERJETATM ) (J9306)
Patients must have a positive 2+ HER 2 and metastatic disease, or a positive 3+ HER 2 test or a positive fish test.
Pertuzumab is indicated in combination with trastuzumab and docetaxel or paclitaxel for the treatment of patients with HER2-positive breast cancer. May be considered in combination with trastuzumab with or without cytotoxic therapy (eg, vinorelbine or taxane) or in cancer in combination with docetaxel or carboplatin (C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922).

Or per NCCN:
C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922. Malignant neoplasm of breast

28. Pralatrexate (Folotyn) 1 mg (J9307) 
C82.50-C82.59 Diffuse or cutaneous follicle center lymphoma
C83.09, C83.89 Other lymphomas
C84.00-C84.09 Mycosis fungoides
C84.11-C84.19 Sezary’s disease
C84.40-C84.49 Peripheral T-cell lymphoma
C84.60-C84.79 Anaplastic large cell lymphoma
C84.90-C84.99 Mature T/NK-cell lymphomas
C84.A0- C84.A9 Cutaneous T-cell lymphoma
C84.Z0- C84.Z9 Other mature T/NK-cell lymphomas
C85.10-C85.19 Unspecified B-cell lymphoma
C85.20- C85.29 Mediastinal (thymic) large B-cell lymphoma
C85.80- C85.89 Other specified types of non-Hodgkin lymphoma
C85.90- C85.99 Non-Hodgkin lymphoma
C86.0- C86.6 Other specified types of cell lymphoma
C91.30, C91.32, C91.50, C91.52, C91.60, C91.62, C91.A0, C91.A2, C91.Z0, C91.Z2 Other lymphoid leukemias

29. Radium Ra 223 dichloride (Xofigo) (A9606)
Coverage is for the FDA approved indication: the treatment of patients with castration-resistant prostate cancer, symptomatic bone metastases and no known visceral metastatic disease. It is administered at 4 week intervals for a total of 6 doses. Use diagnosis codes C61 and C79.51 or C79.52. Coverage is effective 05/15/2013 –FDA approval date.

Off label use is not covered. Do not use both diagnosis codes if the indications have not been met.

30. Ramucirumab (Cyramza) (J9308), 5mg

Covered for advanced gastric cancer or gastro-esophageal junction adenocarcinoma, as a single agent after prior fluoropyrimidine or platinum containing chemotherapy (C15.3-C15.8, C16.0-C16.8). Effective 04/21/2014 –FDA approval date.

Covered in combination with paclitaxel, for treatment of advanced gastric or gastro-esophageal junction adenocarcinoma, with disease progression on or after prior fluoropyrimidine- or platinum-containing chemotherapy (C15.3-C15.8, C16.0-C16.8). Effective 11/05/2014-FDA approval date.

Covered in combination with docetaxel, for treatment of metastatic nonsmall
cell lung cancer with disease progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving CYRAMZA. (C33, C34.01, C34.02, C34.11, C34.12, C34.2, C34.31, C34.32, C34.81, C34.82, C34.91, C34.92) Effective 12/12/2014-FDA approval Date.

Covered in combination with FOLFIRI, for the treatment of metastatic colorectal cancer with disease progression on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine. (C18.3-C21.8), Effective 04/24/2015, FDA approval date.

Or per NCCN:
C15.3-C15.5, C15.8 Malignant neoplasm, esophagus
C16.0-C16.4, C16.8 Malignant neoplasm, stomach
C17.0-C17.2, C17.8 Malignant neoplasm, small intestine
C18.0-C18.8, C19, C20, C21.2, C21.8 Malignant neoplasm, colon.
C33, C34.01, C34.02, C34.11, C34.12, C34.2, C34.31, C34.32, C34.81, C34.82 Malignant neoplasm, trachea, lung or bronchus
C78.01, C78.02, C78.6, C78.7 Secondary malignant neoplasms
D37.1-D37.5, D37.8 Malignant neoplasms of uncertain behavior

31. Rituximab (Rituxan) 100 mg, (J9310)

Post Stem cell transplant and Epstein Barr virus Z94.84 and B27.00-B27.09

Acute refractory and relapsed refractory thrombotic thrombocytopenic purpura (TTP) due to immune-mediated ADAMTS-13 deficiency M31.1

Henoch-Schonlein purpura D69.0. 10/15/2013

Post-transplant lymphoproliferative disorder (PTLD) D47.Z1 and one of the complications of transplant codes below:

Chronic graft-versus-host disease D89.811 and one of the complications of transplant codes:

Complications of Transplant Codes:
T86.01-T86.03. T86.09 Complications of bone marrow transplant
T86.11-T86.13, T86.19 Complications of kidney transplant
T86.21-T86.23, T86.290, T86.298 Complications of heart transplant
T86.31-T86.33, T86.39 Complications of heart-lung transplant
T86.41-T86.43, T86.49 Complications of liver transplant
T86.5 Complications of stem cell transplant
T86.810-T86.812, T86.818 Complications of lung transplant
T86.830-T86.832, T86.838 Complications of bone graft
T86.850-T86.852, T86.858 Complications of intestine transplant
T86.890-T86.892, T86.898, Complications of other transplanted tissue

Additional Indications
C79.32 Secondary malignant neoplasm, cerebral meninges
C81.00-C81.49 Hodgkin lymphoma
C82.00-C82.89 Follicular lymphoma and other types of follicular lymphoma
C82.90-C82.99 Follicular lymphoma, unspecified
C83.00-C83.89 Non-follicular lymphoma
C84.01-C84.09 Mycosis fungoides
C84.10-C84.19 Sezary’s disease
C84.40- C84.49 Peripheral T-cell lymphoma
C84.60- C84.79 Anaplastic large cell lymphoma
C84.90- C84.99 Mature T/NK-cell lymphomas
C84.A0- C84.A9 Cutaneous T-cell lymphoma
C84.Z0- C84.Z9 Other mature T/NK-cell lymphomas
C85.10-C85.19 Unspecified B-cell lymphoma
C85.20- C85.29 Mediastinal (thymic) large B-cell lymphoma
C85.80- C85.89 Other specified types of non-Hodgkin lymphoma
C85.90- C85.99 Non-Hodgkin lymphoma
C86.0- C86.6 Other specified types of T/NK-cell lymphoma
C88.0 Waldenstrom macroglobulinemia
C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue
C91.00- C91.02, C91.10-C91.12 C91.40-C91.42 Lymphoid Leukemia
C96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis
C96.2 Malignant mast cell tumor
C96.4 Sarcoma of dendritic cells (accessory cells)
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
C96.A Histiocytic sarcoma
C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
D36.0 Benign neoplasm lymph nodes
D47.3 Essential (hemorrhagic) thrombocythemia
D59.0, D59.1 Autoimmune hemolytic anemia
D68.311 Acquired hemophilia
D68.32 Hemorrhagic disorder due to extrinsic circulating anticoagulants
D68.4 Acquired coagulation factor deficiency
D69.3 , D69.41, D69.42, D69.49 Immune Thrombocytopenia purpura & Other primary thromboctyopenia
G35 Multiple sclerosis
G36.0 Neuromyelitis optica
I77.6 Arteritis
L10.0 – L10.89 Pemphigus
L12.0, L12.8, L12.9 Bullous pemphigoid, other and unspecified
L12.1 Cicatricial pemphigoid
M05.011, M05.012, M05.021, M05.022, M05.031, M05.032, M05.041, M05.042, M05.051, M05.052, M05.061, M05.062, M05.071, M05.072, M05.09, Felty's syndrome
M05.211, M05.212, M05.221, M05.222, M05.231, M05.232, M05.24 1, M05.242, M05.251, M05.252, M05.261, M05.262, M05.271, M05.272, M05.29 Rheumatoid vasculitis with rheumatoid arthritis
M05.311, M05.312, M05.321, M05.322, M05.331, M05.332, M05.341, M05.342, M05.351, M05.352, M05. 361, M05.362, M05.371, M05.372, M05.39 Rheumatoid heart disease with rheumatoid arthritis
M05.411, M05.412, M05.421, M05.422, M05.431, M05.432, M05.441, M05.442, M05.451, M05.452, M05.461, M05.462, M05.471, M05.472, M05.49 Rheumatoid myopathy with rheumatoid arthritis
M05.511, M05.512, M05.521, M05.522, M05.531, M05.532, M05.541, M05.542, M05.551, M05.552, M05.561, M05.562, M05.571, M05.572, M05.59, Rheumatoid polyneuropathy with rheumatoid arthritis
M05.611, M05.612, M05.621, M05.622, M05.631, M05.632, M05.641, M05.642, M05.651, M05.652, M05.661, M05.662, M05.671, M05.672, M05.69 Rheumatoid arthritis
M05.711, M05.712, M05.721, M05.722, M05.731, M05.732, M05.741, M05.742, M05.751, M05.752, M05.761, M05.762, M05.771, M05.772, M05.79 Rheumatoid arthritis with rheumatoid factor
M05.811, M05.812, M05.821, M05.822, M05.831, M05.832, M05.841, M05.842, M05.851, M05.852, M05.861, M05.862, M05.871, M05.872, M05.89 Other rheumatoid arthritis with rheumatoid factor
M06.011, M06.012, M06.021, M06.022, M06.031, M06.032, M06.041, M06.042, M06.051, M06.052, M06.061, M06.062, M06.071, M06.072, M06.08, M06.09 Rheumatoid arthritis without rheumatoid factor
M06.1 Adult-onset Still's disease
M06.211, M06.212, M06.221, M06.222, M06.231, M06.232, M06.241, M06.242, M06.251, M06.252, M06.261, M06.262, M06.271, M06.272, M06.28, M06.29 Rheumatoid bursitis
M06.311, M06.312, M06.321, M06.322, M06.331, M06.332, M06.341, M06.342, M06.351, M06.352, M06.361, M06.362, M06.371, M06.372, M06.38, M06.39 Rheumatoid nodule
M06.811, M06.812, M06.821, M06.822, M06.831, M06.832, M06.841, M06.842, M06.851, M06.852, M06.861, M06.862, M06.871, M06.872, M06.88, M06.89 Other specified rheumatoid arthritis
M30.0- M30.2, M30.8 Polyarteritis
M31.1 Thrombotic microangiopathy
M31.30, M31.31 Wegener's granulomatosis
M31.7 Microscopic Polymyositis
M33.00-M33.02, M33.09 Juvenile dermatopolymyositis
M33.10-M33.12, M33.19 Other dermatopolymyositis
M33.20-M33.22, M33.29 Polymyositis
M36.0 Dermato(poly)myositis in neoplastic disease
R59.0, R59.1, R59.9 Enlarged lymph nodes

32. Romidepsin (Istodax) 1 mg (J9315)
C82.00-C82.99 Lymphoma
C82.53 Diffuse follicle center lymphoma; intra-abdominal lymph nodes
C83.01-C83.09 Non-follicular lymphomas
C83.81-C83.89 Other non-follicular lymphomas
C84.00-C84.09 Mycosis fungoides
C84.11-C84.19 Sezary’s disease
C84.40- C84.49 Peripheral T-cell lymphoma
C84.60- C84.79 Anaplastic large cell lymphomas
C84.90- C84.99 Mature T/NK-cell lymphomas
C84.A0- C84.A9 Cutaneous T-cell lymphoma
C84.Z0- C84.Z9 Other mature T/NK-cell lymphomas
C85.10-C85.19 Unspecified B-cell lymphoma
C85.20- C85.29 Mediastinal (thymic) large B-cell lymphoma
C85.80- C85.89 Other specified types of non-Hodgkin lymphoma
C85.90- C85.99 Non-Hodgkin lymphoma
C86.0- C86.6 Other specified types of T/NK-cell lymphoma
C91.30-C91.32 Prolymphocytic leukemia-B cell
C91.40-C91.42 Hairy cell leukemia
C91.50-C91.52 Adult T cell lymphoma/leukemia
C91.60-C91.62 Prolymphocytic leukemia-T cell
C91.A0, C91.A2 Mature B cell leukemia
C91.Z0, C91.Z2 Other lymphoid leukemia
C96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis
C96.2 Malignant mast cell tumor
C96.4 Sarcoma of dendritic cells (accessory cells)
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
C96.A Histiocytic sarcoma
C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue

33. Temsirolimus (Torisel™) 1 mg (J9330)
C47.8, C49.8 Malignant neoplasm, peripheral nerves/autonomic nervous system
C64.1, C64.2, C65.1, C65.2 Malignant neoplasm of kidney, renal pelvis
C54.1, C54.2, C54.3, C54.8 Malignant neoplasm of corpus uteri,
D49.2 Neoplasm of unspecified behavior of bone, soft tissue and skin.

34. Trastuzumab (Herceptin) 10 mg (J9355) 
Patients must have a positive 2+ HER 2 and metastatic disease or a positive 3+
HER 2 test or a positive fish test for all diagnosis below:
C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922. Malignant neoplasm of breast
C15.3-C15.5, C15.8, C16.0-C16.6, C16.8 Malignant neoplasm of esophagus, stomach
C07 Malignant neoplasm of parotid gland that is HER-2 positive
C33, C34.01, C34.02, C34.11, C34.12, C34.2, C34.31, C34.32, C34.81, C34.82, C34.91, C34.92 Malignant neoplasm lung, bronchus, and trachea.
C79.32 Secondary malignant neoplasm, cerebral meninges
D37.1, D37.8 Neoplasm of uncertain behavior of stomach or other digestive organ

35. Vincristine sulfate, liposome , 1 mg (Marqibo) (J9371) is covered for the treatment of adult patients with Philadelphia chromosome-negative (Ph-) acute lymphoblastic leukemia (ALL) in second or greater relapse or whose disease has progressed following two or more anti-leukemia therapies (C91.02).

36. ziv-aflibercept 1 mg (ZALTRAP), (J9400)
In combination with 5-fluorouracil, leucovorin, irinotecan-(FOLFIRI), is indicated for patients with metastatic colorectal cancer that is resistant to or has progressed following an oxaliplatin-containing regimen . Effective 08/03/12- FDA approval date. (C18.0, -C18.8, C19, C20, C21.1, C21.2, C21.8)

Or per NCCN:
C17.0-C17.2, C17.8 Malignant neoplasm of small intestine
C18.0-C18.8, C19, C20, C21.0, C21.1, C21.2, C21.8 Malignant neoplasm of colon, anus and anal canal
C78.01, C78.02, C78.7 Secondary malignant neoplasms

D. Not otherwise Classified Agents (NOC) (A9699, J3590, J9999, C9399)
1. Irinotecan liposome (Onivyde) (J9999/C9474)
Approved in combination with fluorocuracil and leucovorin, for the treatment of patients with metastatic adenocarcinoma of the pancreas after disease progression following gemcitabine-based therapy. Onivyde is not indicated as a single agent for the treatment of patients with metastatic adenocarcinoma of the pancreas (C25.0-C25.8). FDA approval date 10/22/2015.

2. Daratumumab (Darzalex) (J3590/C9476)
Indicated for the treatment of patients with multiple myeloma who have received at least three prior lines of therapy including a proteasome inhibitor (PI) and an
immunomodulatory agent or who are double-refractory to a PI and an
immunomodulatory agent. Effective 11/16/2015-FDA approval date (C90.00, C90.02).

3. Talimogene laherparepvec (IMLYGIC) (J3590/C9472)
Indicated for the local treatment of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery. Effective 10/27/2015-FDA approval date (C43.0, C43.10-C43.12, C43.20-C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59-C43.62, C43.70-C43.72, C43.8, C43.9, C80.0, C80.1, Z85.820).

4. Necitumumab (Portrazza) (J3590/C9475)
Indicated in combination with gemcitabine and cisplatin, for first-line treatment
of patients with metastatic squamous non-small cell lung cancer. Limitation of
Use: not indicated for treatment of non-squamous non-small cell lung cancer.
Effective 11/24/2015- FDA approval date (C33, C34.00-C34.02, C34.10-
C34.12, C34.2, C34.30-C34.32, C34.80-C34.82, C34.90-C34.92).

5. Elotuzumab (Empliciti) (J3590)/C9477)
Indicated in combination with lenalidomide and dexamethasone for the treatment of patients with multiple myeloma who have received one to three prior therapies- Effective 11/30/2015, FDA approval date (C90.00, C90.02, C90.10, C90.12, C90.20, C90.22, C90.30, C90.32).

6. Trabectedin (Yondelis) (J9999/C9480)
For the treatment of unresectable or metastatic liposarcoma or leiomyosarcoma who received a prior anthracycline containing regimen (C48.0-C48.2, C48.8, C49.0, C49.10-C49.12, C49.20-C49.22, C49.3-C49.6, C49.8, C49.9, C53.0, C54.0-C54.3, C54.8, C54.9, C55, C78.00-C78.02). Effective 10/23/2015-FDA approval date.
Note: NOC for administration and pump: Please use CPT G0498: this is the single service that INCLUDES the chemotherapy administration AND the pump. G0498 will be inclusive for all of these costs, no other administration, pump charge, set up or disconnect charges would be allowed.
Effective 01/01/2016 per CR 9749.

7. Atezolizumab (Tecentriq) (J3590/C9399)
For the treatment of patients with locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing chemotherapy or have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy (C65.1-C65.9, C66.1-C66.9, C67.0-C67.9, C68.0). Effective 05/18/2016 -FDA approval date.

E. Coverage of Cyclophosphamide (J9070) and Methotrexate (J9250, J9260) for indications other than oncologic diseases.
1. Cyclophosphamide (J9070)
C88.0 Waldenstrom macroglobulinemia
D47.2 Monoclonal gammopathy
D47.3 Essential (hemorrhagic) thrombocythemia
D47.Z2 Castleman disease
D59.0 Drug-induced autoimmune hemolytic anemia
D59.1 Other autoimmune hemolytic anemias
D69.3 Immune thrombocytopenic purpura
D69.41 Evans syndrome
D69.42 Congenital and hereditary thrombocytopenia purpura
D69.49 Other primary thrombocytopenia
D89.0 Polyclonal hypergammaglobulinemia
D89.1 Cryoglobulinemia
E85.9 systemic light chain amyloidosis
E88.09-effective 10/16/2015 Other disorders of plasma protein metabolism, not elsewhere classified
G35 Multiple sclerosis
G60.3 Idiopathic progressive neuropathy
I77.6 Arteritis, unspecified
M05.411, M05.412, M05.421, M05.422, M05.431, M05.432, M05.441, M05.442, M05.451, M05.452, M05.461, M05.462, M05.471, M05.472, M05.49 Rheumatoid myopathy with rheumatoid arthritis
M05.511, M05.512, M05.521, M05.522, M05.531, M05.532, M05.541, M05.542, M05.551, M05.552, M05.561, M05.562, M05.571, M05.572, M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis
M05.711, M05.712, M05.721, M05.722, M05.731, M05.732, M05.741, M05.742, M05.751, M05.752, M05.761, M05.762, M05.771, M05.772, M05.79 Rheumatoid arthritis with rheumatoid factor
M06.011, M06.012, M06.021, M06.022, M06.031, M06.032, M06.041, M06.042, M06.051, M06.052, M06.061, M06.062, M06.071, M06.072, M06.08, M06.09 Rheumatoid arthritis without rheumatoid factor
M06.211, M06.212, M06.221, M06.222, M06.231, M06.232, M06.241, M06.242, M06.251, M06.252, M06.261, M06.262, M06.271, M06.272, M06.28, M06.29 Rheumatoid bursitis
M06.311, M06.312, M06.321, M06.322, M06.331, M06.332, M06.341, M06.342, M06.351, M06.352, M06.361, M06.362, M06.371, M06.372, M06.38, M06.39 Rheumatoid nodule
M30.0 Polyarteritis nodosa
M30.1 Polyarteritis with lung involvement [Churg-Strauss]
M30.2 Juvenile polyarteritis
M31.30,M31.31 Wegener's granulomatosis
M31.7 Microscopic polyangiitis
M32.0, M32.10-M32.15, M32.19, M32.8 lupus erythematosus
M34.0 Progressive systemic sclerosis
M34.1 CR(E)ST syndrome
M34.2 Systemic sclerosis induced by drug and chemical
M34.81-M34.83, M34.89 Systemic sclerosis
N02.0-N02.8 Recurrent and persistent hematuria
N04.0-N04.8 Nephrotic syndrome
R59.0-R59.1 Enlarged lymph nodes

2. Methotrexate (J9250, J9260)
I77.6 Arteritis
J84.111-J84.117 Idiopathic interstitial pneumonia
L12.0, L12.8, L12.9 Pemphigoid
L40.0-L40.9 Psoriasis
M02.311, M02.312, M02,321, M02.331, M02.312, M02.331, M02.332, M02.341, M02.342, M02.351, M02.352, M02.361, M02.362, M02.371, M02.372, M02.38, M02.39 Reiter's disease
M05.211, M05.212, M05.221, M05.222, M05.231, M05.232, M05.241, M05.242, M05.251, M05.252, M05.261, M05.262, M05.271, M05.272, M05.29 Rheumatoid vasculitis with rheumatoid arthritis
M05.311, M05.312, M05.321, M05.322, M05.331, M05.332, M05.341, M05.342, M05.351, M05.352, M05.361, M05.362, M05.371, M05.372, M05.39 heart disease with rheumatoid arthritis
M05.411, M05.412, M05.421, M05.422, M05.431, M05.432, M05.441, M05.442, M05.451, M05.452, M05.461, M05.462, M05.471, M05.472, M05.49 Rheumatoid myopathy with rheumatoid arthritis
M05.511, M05.512, M05.521, M05.522, M05.531, M05.532, M05.541, M05.542, M05.551, M05.552, M05.561, M05.562, M05.571, M05.572, M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis
M05.611, M05.612, M05.621, M05.622, M05.631, M05.632, M05.641, M05.642, M05.651, M05.652, M05.661, M05.662, M05.671, M05.672, M05.69 Rheumatoid arthritis
M05.711, M05.712, M05.721, M05.722, M05.731, M05.732, M05.741, M05.742, M05.751, M05.752, M05.761, M05.762, M05.771, M05.772, M05.79 Rheumatoid arthritis with rheumatoid factor
M05.811, M05.812, M05.821, M05.822, M05.831, M05.832, M05.841, M05.842, M05.851, M05.852, M05.861, M05.862, M05.871, M05.872, M05.89 Other rheumatoid arthritis with rheumatoid factor
M06.011, M06.012, M06.021, M06.022, M06.031, M06.032, M06.041, M06.042, M06.051, M06.052, M06.061, M06.062, M06.071, M06.072, M06.08, M06.09 Rheumatoid arthritis without rheumatoid factor
M06.1 Adult-onset Still's disease
M06.211, M06.212, M06.221, M06.222, M06.231, M06.232, M06.241, M06.242, M06.251, M06.252, M06.261, M06.262, M06.271, M06.272, M06.28, M06.29 Rheumatoid bursitis
M06.311, M06.312, M06.321, M06.322, M06.331, M06.332, M06.341, M06.342, M06.351, M06.352, M06.361, M06.362, M06.371, M06.372, M06.38, M06.39 Rheumatoid nodule
M06.4 Inflammatory polyarthropathy
M06.811, M06.812, M06.821, M06.822, M06.831, M06.832, M06.841, M06.842, M06.851, M06.852, M06.861, M06.862, M06.871, M06.872, M06.88, M06.89 Other specified rheumatoid arthritis
M08.1 Juvenile ankylosing spondylitis
M08.211, M08.212, M08.221, M02.222, M08.231, M08.232, M08.241, M08.242, M08.251, M08.252, M08.261, M08.262, M08.271, M08.272, M08.28, M08.29 Juvenile rheumatoid arthritis with systemic onset
M08.3 Juvenile rheumatoid polyarthritis (seronegative)
M08.811, M08.812, M08.821, M08.822, M08.831, M08.832, M08.841, M08.842, M08.851, M08.852, M08.861, M08.862, M08.871, M08.872, M08.88, M08.89 Other juvenile arthritis
M31.5, M31.6 Giant cell arteritis
M32.0, M32.10-M32.19, M32.8 Systemic lupus erythematosus
M33.21, M33.22, M33.29 Polymyositis
M35.04 Sicca syndrome with tubulo-interstitial nephropathy
M45.0-M45.8 Ankylosing spondylitis
M48.8X1-M48.8X8 Other specified spondylopathies
N08 Glomerular disorders in diseases classified elsewhere
O0000 Abdominal pregnancy without intrauterine pregnancy
O0001 Abdominal pregnancy with intrauterine pregnancy
O0010 Tubal pregnancy without intrauterine pregnancy
O0011 Tubal pregnancy with intrauterine pregnancy
O0020 Ovarian pregnancy without intrauterine pregnancy
O0021 Ovarian pregnancy with intrauterine pregnancy
O0080 Other ectopic pregnancy without intrauterine pregnancy
O0081 Other ectopic pregnancy with intrauterine pregnancy


Non-Facility Injection Services

E/M services provided in a non-facility setting are considered an inherent component for providing an injection service.

CPT indicates these services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61 and an E/M service is provided on the same date of service, by the Same Individual Physician or Other Health Care Professional only the appropriate therapeutic and diagnostic injection(s) will be reimbursed and the EM service is not separately reimbursed.

If a significant, separately identifiable EM service is performed unrelated to the physician work (injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff, etc.) required for the injection service, modifier 25 may be reported for the E/M service in addition to 96372-96379. If the E/M service does not meet the requirement for a significant separately identifiable service, then modifier 25 would not be reported and a separate E/M service would not be reimbursed.

2 comments:

Anonymous said...

for J3301 if injection given 1cc is equal to 40mg agreed ..but what about J3302 injection how many units are billable if 1cc given?

http://www.bloggerpk.com/

Anonymous said...

I'm looking at the directions for J0702 and want to know where I can verify this...everything else I'm coming across appears to say 1 unit is per ml, which would only be 5 per vial rather than 10, I believe.

Top Medicare billing tips