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  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule68152-0103-03 A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN ZEVALIN Y-90 VIAL 9/1/2013 99/99/9999 M0150419-0320-05 A9581 INJECTION, GADOXETATE DISODIUM, 1 ML EOVIST 2.5 MMOL/10 ML VIAL 10/1/2011 99/99/9999 M0100003-2187-10 J0129 ABATACEPT INJECTION ORENCIA 250 MG VIAL 7/1/2015 99/99/9999 M0100002-7140-01 J0130 ABCIXIMAB REOPRO 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100074-3799-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML SYRINGE 7/1/2015 99/99/9999 M0100074-4339-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML PEN 7/1/2015 99/99/9999 M0100074-4339-06 J0135 INJECTION (HUMIRA) HUMIRA CROHN'S STARTER PACK 7/1/2015 99/99/9999 M0100409-4901-18 J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 0.1 MG/ML SYRINGE 1/1/2013 99/99/9999 M0100409-7241-01 J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 1 MG/ML AMPUL 1/1/2013 99/99/9999 M0142023-0122-25 J0171 ADRENALIN EPINEPHRINE INJECT ADRENALIN CL 1 MG/ML VIAL 1/1/2013 9/30/2014 M0149502-0500-02 J0171 ADRENALIN EPINEPHRINE INJECT EPIPEN 2-PAK 0.3 MG AUTO-INJCT 1/1/2013 99/99/9999 M0176329-3316-01 J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 0.1 MG/ML SYRINGE 1/1/2013 99/99/9999 M0158468-0040-01 J0180 AGALSIDASE INJECTION FABRAZYME 35 MG VIAL 7/1/2015 99/99/9999 M0158468-0041-01 J0180 AGALSIDASE INJECTION FABRAZYME 5 MG VIAL 7/1/2015 99/99/9999 M0162756-0581-40 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 3/31/2014 M0162756-0581-42 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 3/31/2014 M0155390-0308-03 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 12/31/2016 M0158178-0017-01 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/2013 M0158178-0017-03 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/2013 M0158468-0150-01 J0220 ALGLUCOSIDASE ALFA INJECTION MYOZYME 50 MG VIAL 7/1/2015 99/99/9999 M0158468-0160-01 J0221 LUMIZYME INJECTION LUMIZYME 50 MG VIAL 1/1/2012 99/99/9999 M0100053-7201-02 J0256 ALPHA 1 PROTEINASE INHIBITOR ZEMAIRA 1,000 MG VIAL 7/1/2015 99/99/9999 M0100944-2884-01 J0257 GLASSIA INJECTION GLASSIA 1 GM/50 ML VIAL 1/1/2012 99/99/9999 M0100009-3169-06 J0270 INJECTION, ALPPROSTADIL PROSTIN VR PEDI 500 MCG/ML AMP 7/1/2015 99/99/9999 M0100009-3701-05 J0270 INJECTION, ALPPROSTADIL CAVERJECT 20 MCG VIAL 7/1/2015 99/99/9999 M0100009-5181-01 J0270 INJECTION, ALPPROSTADIL CAVERJECT IMPULSE 10 MCG KIT 7/1/2015 99/99/9999 M0100009-5182-01 J0270 INJECTION, ALPPROSTADIL CAVERJECT IMPULSE 20 MCG KIT 7/1/2015 99/99/9999 M0100009-7686-04 J0270 INJECTION, ALPPROSTADIL CAVERJECT 40 MCG VIAL 7/1/2015 99/99/9999 M0100703-1501-02 J0270 INJECTION, ALPPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 7/1/2015 99/99/9999 M0100703-9032-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100703-9040-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 1 GRAM/4 ML VIAL 7/1/2015 99/99/9999 M0155390-0226-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 7/1/2015 7/31/2015 M0100409-5921-01 J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 7/1/2015 99/99/9999 M0100409-5922-01 J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 7/1/2015 99/99/9999 M0139822-1055-05 J0285 AMPHOTERICIN B AMPHOTERICIN B 50 MG VIAL 7/1/2015 99/99/9999 M0157665-0101-41 J0287 INJECTION AMPHOTERICIN B LIPID COMPLEX ABELCET 100 MG/20 ML VIAL 7/1/2015 99/99/9999 M0100469-3051-30 J0289 INJECT, AMPHOTERICIN B LIPOSOME AMBISOME 50 MG VIAL 7/1/2015 99/99/9999 M0100781-3400-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 7/1/2015 99/99/9999 M0100781-3402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 7/1/2015 99/99/9999 M0100781-3404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100781-3407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100781-3408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 7/1/2015 99/99/9999 M0100781-3409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100781-3412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 7/1/2015 99/99/9999 M0100781-3413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 7/1/2015 99/99/9999 M0100781-9401-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 7/1/2015 99/99/9999 M0100781-9402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 7/1/2015 99/99/9999 M0100781-9404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100781-9407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100781-9408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 7/1/2015 99/99/9999 M0100781-9409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100781-9412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 7/1/2015 99/99/9999 M0100781-9413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 7/1/2015 99/99/9999 M0163323-0387-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 7/1/2015 99/99/9999 M0163323-0388-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0389-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 7/1/2015 99/99/9999 M0163323-0399-23 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 7/1/2015 99/99/9999 M0100049-0013-83 J0295 AMPICILLIN/SULBACTAM 1.5GM UNASYN 1.5 GM VIAL 7/1/2015 99/99/9999 M0100049-0014-83 J0295 AMPICILLIN/SULBACTAM 1.5GM UNASYN 3 GM VIAL 7/1/2015 99/99/9999 M0100049-0024-28 J0295 AMPICILLIN/SULBACTAM 1.5GM UNASYN 15 GM VIAL 7/1/2015 99/99/9999 M0100409-2687-15 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 15 GM VL 7/1/2015 99/99/9999 M0100409-2689-01 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0100409-2987-03 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULB 3 GM ADD VIAL 7/1/2015 99/99/9999 M0100409-2988-01 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0100409-2998-03 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 3 GM VIAL 7/1/2015 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00781-3032-95 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0100781-3033-95 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 3 GM VIAL 7/1/2015 99/99/9999 M0100781-3034-46 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 15 GM VL 7/1/2015 99/99/9999 M0163323-0368-20 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0163323-0369-20 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 3 GM VIAL 7/1/2015 99/99/9999 M0163323-0370-62 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 15 GM VL 7/1/2015 99/99/9999 M0100409-6629-02 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 200 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100781-3009-95 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T ANECTINE 20 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0614-01 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0614-55 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 7/1/2015 99/99/9999 M0159148-0016-65 J0400 ARIPIPRAZOLE INJECTION ABILIFY 9.7 MG/1.3 ML VIAL 7/1/2015 99/99/9999 M0100069-3150-83 J0456 INJECTION, AZITHROMYCIN ZITHROMAX I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0150111-0794-78 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0398-10 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0398-12 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0100517-1010-25 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 1 MG/ML VIAL 3/1/2010 99/99/9999 M0100641-6006-10 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 8 MG/20 ML VIAL 8/29/2012 99/99/9999 M0100409-4910-34 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 0.1 MG/ML ABBOJECT 3/1/2010 99/99/9999 M0158281-0560-01 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0560-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0561-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/5 ML KIT 7/1/2015 99/99/9999 M0158281-0563-01 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0563-02 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0562-01 J0476 BACLOFEN LIORESAL IT 0.05 MG/1 ML AMP 7/1/2015 99/99/9999 M0100078-0331-84 J0480 INJECTION, BASILIXIMAB SIMULECT 20 MG VIAL 7/1/2015 99/99/9999 M0100078-0393-61 J0480 INJECTION, BASILIXIMAB SIMULECT 10 MG VIAL 7/1/2015 99/99/9999 M0149401-0101-01 J0490 BELIMUMAB INJECTION BENLYSTA 120 MG VIAL 1/1/2012 99/99/9999 Y M0149401-0102-01 J0490 BELIMUMAB INJECTION BENLYSTA 400 MG VIAL 1/1/2012 99/99/9999 Y M0158914-0080-52 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG BENTYL 10 MG/ML AMPUL 7/1/2015 99/99/9999 M0160793-0700-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 600,000 UNIT/ML 1/1/2011 99/99/9999 M0160793-0131-10 J0561 PENICILLIN G BENZATHINE INJ PEN G 1.2 MILLION UNIT/2 ML 1/1/2011 99/99/9999 M0160793-0600-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN C-R 1.2 MILLION UNIT 1/1/2011 99/99/9999 M0160793-0701-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 1,200,000 UNITS 1/1/2011 99/99/9999 M0160793-0702-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 2,400,000 UNITS 1/1/2011 99/99/9999 M0115054-0530-06 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 300 UNIT VIAL 4/1/2012 3/31/2013 M0115054-0500-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 500 UNITS VIAL 4/1/2012 3/31/2013 M0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/2012 99/99/9999 M0100023-9232-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 100 UNITS VIAL 4/1/2012 99/99/9999 M0100023-9232-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/2012 12/31/2012 M0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/2012 99/99/9999 M0100023-3919-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/2012 99/99/9999 M0100023-3921-02 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 200 UNITS VIAL 4/1/2012 99/99/9999 M0115054-0500-01 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 500 UNITS VIAL 4/1/2013 99/99/9999 M0115054-0530-06 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 300 UNIT VIAL 4/1/2013 99/99/9999 M0110454-0710-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 2,500 UNIT/0.5 ML VIAL 2/1/2013 99/99/9999 M0110454-0711-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 5,000 UNITS/1 ML VIAL 2/1/2013 99/99/9999 M0110454-0712-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 10,000 UNITS/2 ML VIAL 2/1/2013 99/99/9999 M0100259-1605-01 J0588 INCOBOTULINUMTOXIN A XEOMIN 50 UNITS VIAL 1/1/2012 99/99/9999 M0100259-1610-01 J0588 INCOBOTULINUMTOXIN A XEOMIN 100 UNITS VIAL 1/1/2012 99/99/9999 M0100409-2012-32 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENORPHINE 0.3 MG/ML SYRN 7/1/2015 99/99/9999 M0112496-0757-01 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENEX 0.3 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1623-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1626-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1626-02 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 7/1/2015 99/99/9999 M0163833-0825-02 J0598 C-1 ESTERASE, CINRYZE BERINERT 500 UNIT KIT 2/1/2013 99/99/9999 M0100517-3900-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0163323-0311-10 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0163323-0311-50 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0163323-0311-61 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0100078-0149-23 J0630 INJECTION, CALCITONIN SALMON, UP TO 400 MIACALCIN 200 UNIT/ML VIAL 7/1/2015 99/99/9999 M0100078-0582-61 J0638 CANAKINUMAB INJECTION ILARIS 180 MG VIAL 1/1/2013 99/99/9999 M0125021-0815-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 2/15/2013 99/99/9999 M0125021-0816-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 2/15/2013 99/99/9999 M0100703-5140-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 99/99/9999 M0100703-5145-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule55390-0009-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 6/30/2013 M0155390-0051-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 50 MG VIAL 3/1/2008 8/31/2013 M0155390-0052-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 8/31/2014 M0155390-0053-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 4/30/2014 M0155390-0054-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 2/28/2015 M0155390-0818-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 8/31/2014 M0155390-0824-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 4/30/2014 M0155390-0825-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 5/31/2013 M0155390-0826-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 6/30/2013 M0163323-0711-00 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 500 MG VL 3/1/2008 99/99/9999 M0163323-0710-50 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 8/30/2011 99/99/9999 M0168152-0101-00 J0641 LEVOLEUCOVORIN INJECTION FUSILEV I.V. 50 MG VIAL 7/1/2015 99/99/9999 M0100409-1036-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 7/1/2015 99/99/9999 M0100409-1038-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 7/1/2015 99/99/9999 M0100409-1041-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1.5% VIAL 7/1/2015 99/99/9999 M0100409-1067-20 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 7/1/2015 99/99/9999 M0100409-2047-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 7/1/2015 99/99/9999 M0125021-0100-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100143-9923-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100143-9924-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100143-9983-91 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100264-3103-11 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM-D5W BAG 7/1/2015 99/99/9999 M0100338-3503-41 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM-D5W BAG 7/1/2015 99/99/9999 M0100409-2585-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM ADD-VAN VIAL 7/1/2015 99/99/9999 M0100781-3450-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100781-3451-96 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100781-3452-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0160505-0749-04 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0749-05 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0769-00 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0163323-0236-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0237-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0163323-0238-61 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100409-0805-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0681-00 J0692 INJECTION CEFEPIME HCL 2 GRAM VIAL 7/1/2015 99/99/9999 M0160505-0681-04 J0692 INJECTION CEFEPIME HCL 2 GRAM VIAL 7/1/2015 99/99/9999 M0160505-0834-00 J0692 INJECTION CEFEPIME HCL 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0834-04 J0692 INJECTION CEFEPIME HCL 1 GM VIAL 7/1/2015 99/99/9999 M0100264-3123-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM PIGGYBACK BAG 7/1/2015 99/99/9999 M0100264-3125-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM PIGGYBACK BAG 7/1/2015 99/99/9999 M0160505-0759-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0760-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM VIAL 7/1/2015 99/99/9999 M0160505-0761-04 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 7/1/2015 99/99/9999 M0163323-0343-61 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 7/1/2015 99/99/9999 M0155390-0310-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2014 M0125021-0104-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 12/30/2008 12/31/2010 M0125021-0105-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/2008 99/99/9999 M0125021-0106-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 12/30/2008 99/99/9999 M0125021-0107-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 12/30/2008 99/99/9999 M0100517-8711-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/2/2008 12/31/2012 M0100517-8722-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/2/2008 12/31/2012 M0100517-8725-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/2008 12/31/2012 M0100517-8750-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/2008 12/31/2012 M0168330-0005-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/2/2008 9/30/2011 M0155390-0309-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 11/9/2009 12/31/2014 M0155390-0311-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/1/2009 12/31/2014 M0100069-4481-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2011 M0100069-4481-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2011 M0100069-4482-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/2012 M0100069-4482-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/2012 M0100703-0315-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 5/29/2008 1/31/2013 M0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/2011 M0100703-0335-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 4/30/2013 M0100703-0346-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 5/29/2008 1/31/2013 M0100703-0359-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 5/29/2008 1/31/2013 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00781-3208-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 99/99/9999 M0168330-0006-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 5/29/2008 9/30/2011 M0100781-9328-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100143-9856-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/30/2008 99/99/9999 M0100143-9857-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 1/1/2010 99/99/9999 M0100143-9858-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/2008 99/99/9999 M0100143-9859-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/2008 99/99/9999 M0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/2011 M0100004-1962-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/2008 M0100004-1963-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/2008 7/31/2014 M0100004-1963-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/2008 7/31/2014 M0100004-1964-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/2008 2/28/2015 M0100004-1964-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/2008 2/28/2015 M0100004-1965-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 2 GM VIAL 3/1/2008 8/31/2008 M0100004-1971-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 10 GM VIAL 3/1/2008 8/31/2008 M0100264-3153-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM-D5W BAG 3/1/2008 99/99/9999 M0100264-3155-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM-D5W BAG 3/1/2008 99/99/9999 M0100338-5002-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/2008 99/99/9999 M0100338-5003-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/2008 99/99/9999 M0100409-7332-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100409-7333-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100409-7333-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100409-7334-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0100409-7335-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0100409-7336-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/2008 99/99/9999 M0100409-7336-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/2008 99/99/9999 M0100409-7337-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0100409-7338-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-3206-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0100781-9326-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 7/31/2015 M0110019-0098-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0110019-0098-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0110019-0685-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 12/31/2011 M0110019-0685-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2013 M0110019-0686-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 12/31/2011 M0110019-0686-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2013 M0110019-0687-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 12/31/2011 M0110019-0687-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2013 M0110019-0688-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 12/31/2014 M0110019-0688-27 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 12/31/2014 M0110019-0689-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 12/31/2014 M0160505-0679-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0160505-0679-08 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/2008 99/99/9999 M0160505-0679-09 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/2008 99/99/9999 M0160505-0750-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0160505-0750-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0160505-0751-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0160505-0751-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0160505-0752-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0160505-0752-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0160505-0753-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0160505-0753-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0163323-0344-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0163323-0345-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0163323-0346-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0163323-0347-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0163323-0348-61 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0168180-0611-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0168180-0611-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0168180-0622-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0168180-0622-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0168180-0633-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0168180-0633-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0168180-0644-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0168180-0644-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule68330-0001-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 M0168330-0001-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 M0168330-0002-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011 M0168330-0002-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011 M0168330-0003-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2011 M0168330-0003-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2011 M0168330-0004-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/2011 M0168330-0004-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/2011 M0164679-0701-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0164679-0701-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0164679-0701-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 M0164679-0702-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0164679-0703-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0164679-0703-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0164679-0983-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0164679-0983-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0164679-0702-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-3207-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-3208-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100781-3209-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0100781-3210-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0100781-9327-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-9328-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100781-9329-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 8/31/2015 M0100781-9330-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 6/30/2015 M0100781-3206-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 7/17/2009 99/99/9999 M0100781-3207-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/2008 99/99/9999 M0100781-9326-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/30/2011 7/31/2015 M0100781-9327-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 8/16/2012 99/99/9999 M0100004-1962-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/2008 M0100143-9976-91 J0697 INJECTION, STERILE CEFUROXIME SODIUM, P CEFUROXIME SOD 7.5 GM VIAL 7/1/2015 99/99/9999 M0100143-9977-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM, P CEFUROXIME SOD 1.5 GM VIAL 7/1/2015 99/99/9999 M0100143-9979-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM, P CEFUROXIME SOD 750 MG VIAL 7/1/2015 99/99/9999 M0100039-0018-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 7/1/2015 1/31/2016 M0100039-0019-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 7/1/2015 1/31/2016 M0100039-0020-01 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 10 GM VIAL 7/1/2015 1/31/2016 M0100039-0023-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM ADD-VANTAGE VL 7/1/2015 7/31/2015 M0100039-0037-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM/50 ML GALAXY 7/1/2015 99/99/9999 M0100039-0038-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM/50 ML GALAXY 7/1/2015 99/99/9999 M0100143-9930-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 7/1/2015 99/99/9999 M0100143-9931-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 7/1/2015 99/99/9999 M0100143-9933-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 7/1/2015 99/99/9999 M0100143-9935-91 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 10 GM VIAL 7/1/2015 99/99/9999 M0100085-0566-05 J0702 INJECTION, BETAMETHASONE ACETATE CELESTONE SOLUSPAN 6 MG/ML 7/1/2015 99/99/9999 M0100456-0400-10 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 400 MG VIAL 1/1/2012 99/99/9999 M0100456-0600-01 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 600 MG VIAL 1/1/2012 99/99/9999 M0100456-0600-10 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 600 MG VIAL 1/1/2012 99/99/9999 M0100409-5082-16 J0713 CEFTAZIDIME TAZICEF 1 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5082-52 J0713 CEFTAZIDIME TAZICEF 1 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5084-11 J0713 CEFTAZIDIME TAZICEF 2 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5084-51 J0713 CEFTAZIDIME TAZICEF 2 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5086-11 J0713 CEFTAZIDIME TAZICEF 6 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5086-51 J0713 CEFTAZIDIME TAZICEF 6 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5092-16 J0713 CEFTAZIDIME TAZICEF 1 GM ADD-VANTAGE VIAL 7/1/2015 99/99/9999 M0100409-5092-52 J0713 CEFTAZIDIME TAZICEF 1 GM ADD-VANTAGE VIAL 7/1/2015 99/99/9999 M0100409-5093-11 J0713 CEFTAZIDIME TAZICEF 2 GM ADD-VANTAGE 7/1/2015 99/99/9999 M0100781-3177-96 J0713 CEFTAZIDIME CEFTAZIDIME 1 GM VIAL 7/1/2015 99/99/9999 M0100781-3178-95 J0713 CEFTAZIDIME CEFTAZIDIME 2 GM VIAL 7/1/2015 99/99/9999 M0100781-3179-86 J0713 CEFTAZIDIME CEFTAZIDIME 6 GM VIAL 7/1/2015 99/99/9999 M0163323-0011-15 J0720 INJECTION, CHLORAMPHENICOL SODIUM SUCCIN CHLORAMPHEN NA SUCC 1 GM VL 7/1/2015 99/99/9999 M0100052-0315-10 J0725 INJECTION, CHORIONIC GONADOTROPIN PREGNYL 10,000 UNITS VIAL 7/1/2015 99/99/9999 M0155566-1501-01 J0725 INJECTION, CHORIONIC GONADOTROPIN NOVAREL 10,000 UNITS VIAL 7/1/2015 99/99/9999 M0163323-0025-10 J0725 INJECTION, CHORIONIC GONADOTROPIN CHORIONIC GONAD 10,000 UNIT VL 7/1/2015 99/99/9999 M0100006-3514-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 7/1/2015 99/99/9999 M0100006-3516-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 7/1/2015 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00006-3551-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 7/1/2015 99/99/9999 M0100006-3552-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 7/1/2015 99/99/9999 M0100409-4765-86 J0744 INJECTION CIPROFLOXACIN 200 MG/20 ML VL 7/1/2015 99/99/9999 M0100409-4778-86 J0744 INJECTION CIPROFLOXACIN 400 MG/40 ML VL 7/1/2015 99/99/9999 M0100574-0858-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 7/1/2015 99/99/9999 M0139822-0615-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 7/1/2015 99/99/9999 M0155566-0302-01 J0795 INJECTION, CORTICORELIN OVINE TRIFLUTATE ACTHREL 100 MCG VIAL 7/1/2015 99/99/9999 M0163004-7731-01 J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS HP ACTHAR GEL 80 UNIT/ML VIAL 7/1/2015 99/99/9999 M0100781-3440-71 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG COSYNTROPIN 0.25 MG VIAL 7/1/2013 99/99/9999 M0100781-3052-95 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG COSYNTROPIN 0.25 MG/ML 1/1/2013 99/99/9999 M0100548-5900-00 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG CORTROSYN 0.25 MG VIAL 1/1/2013 12/31/2014 M0100548-5900-00 J0834 INJECTION, COSYNTROPIN, 0.25 MG CORTROSYN 0.25 MG VIAL 1/1/2014 12/31/2014 M0100281-0330-10 J0840 CROTALIDAE POLY IMMUNE FAB CROFAB VIAL 1/1/2012 6/30/2013 M0167919-0011-01 J0878 DAPTOMYCIN INJECTION CUBICIN 500 MG VIAL 7/1/2015 99/99/9999 M0155513-0002-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0002-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0003-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0003-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0004-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0004-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0005-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0005-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0006-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0021-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0021-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0023-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0023-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0025-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0025-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0027-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0027-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0028-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0032-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 500 MCG/1 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0053-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 7/1/2015 99/99/9999 M0155513-0053-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 7/1/2015 99/99/9999 M0155513-0057-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 7/1/2015 99/99/9999 M0155513-0057-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 7/1/2015 99/99/9999 M0155513-0110-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0111-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/0.6 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0025-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0027-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 150 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0057-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/0.42 ML SYRING 7/1/2015 99/99/9999 M0155513-0002-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0003-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 40 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0005-01 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0126-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0126-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0144-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0144-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0148-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0148-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0267-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0267-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0283-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 7/1/2015 99/99/9999 M0155513-0283-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 7/1/2015 99/99/9999 M0155513-0478-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0478-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0302-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 2,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0303-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 3,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0304-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 4,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0310-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0310-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0320-04 J0885 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0340-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 40,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0320-04 J0886 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 5/1/2011 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00078-0347-51 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL 2 GRAM VIAL 7/1/2015 99/99/9999 M0100078-0467-91 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL MESYLATE 500 MG VL 7/1/2015 99/99/9999 M0100409-2336-10 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 7/1/2015 99/99/9999 M0100409-2337-25 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 7/1/2015 99/99/9999 M0155513-0730-01 J0897 DENOSUMAB INJECTION XGEVA 120 MG/1.7 ML VIAL 1/1/2012 99/99/9999 M0155513-0710-01 J0897 DENOSUMAB INJECTION PROLIA 60 MG/ML SYRINGE 1/1/2012 99/99/9999 M0100009-0271-01 J1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP DEPO-ESTRADIOL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-02 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-51 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-52 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-3073-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-3073-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100703-0031-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100703-0031-04 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100703-0043-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100703-0045-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100781-3132-95 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/2010 99/99/9999 M0100781-3132-71 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/2010 99/99/9999 M0100781-3137-75 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100703-0051-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100703-0051-04 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100703-0063-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100009-0306-12 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-0306-02 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-03 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3073-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3073-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-23 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-0306-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 3/31/2015 M0100009-0626-01 J1050 MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 400 MG/ML VIAL 7/1/2015 99/99/9999 M0100703-6801-01 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0100703-6801-04 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0100009-0746-30 J1050 MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0746-35 J1050 MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 7/1/2015 99/99/9999 M0159762-4537-02 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0159762-4537-01 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0100009-0347-02 J1071 INJ TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 100 MG/ML VL 1/1/2015 99/99/9999 M0100781-3073-70 J1071 INJ TESTOSTERONE CYPIONATE TESTOSTERONE CYP 100 MG/ML 1/1/2015 99/99/9999 M0100009-0417-01 J1071 INJ TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML 1/1/2015 99/99/9999 M0100009-0417-02 J1071 INJ TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML 1/1/2015 99/99/9999 M0100591-3223-79 J1071 INJ TESTOSTERONE CYPIONATE TESTOSTERON CYP 2,000 MG/10 ML 1/1/2015 5/31/2017 M0100641-0367-21 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/2/2008 99/99/9999 M0100069-4541-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/16/2012 8/31/2015 M0100069-4543-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/16/2012 3/31/2015 M0100069-4543-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/30/2011 3/31/2015 M0100069-4545-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 8/30/2011 4/30/2015 M0100069-4541-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/30/2011 8/31/2015 M0100517-4901-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/2008 12/31/2014 M0100517-4905-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/2008 12/31/2014 M0100517-4930-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/2008 12/31/2014 M0100641-0367-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 99/99/9999 M0100703-3524-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 2/28/2011 M0100703-3524-03 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 3/31/2011 M0163323-0165-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0165-05 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/2008 99/99/9999 M0163323-0165-30 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/2008 99/99/9999 M0163323-0506-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0516-10 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 3/1/2008 99/99/9999 M0100054-3176-44 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE INTENSOL 1MG/1ML 3/1/2008 99/99/9999 M0100574-0850-05 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 7/1/2015 99/99/9999 M0100574-0850-10 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 7/1/2015 99/99/9999 M0166490-0041-01 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG D.H.E.45 1 MG/ML AMPUL 7/1/2015 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00641-1410-35 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 500 MCG/2 ML AMPULE 7/1/2015 99/99/9999 M0100781-3059-95 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 500 MCG/2 ML AMPULE 7/1/2015 99/99/9999 M0100143-9881-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 250 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100143-9882-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 100 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100641-0493-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 7/1/2015 99/99/9999 M0100641-2555-45 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 7/1/2015 99/99/9999 M0117478-0540-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML VL 11/10/2010 99/99/9999 M0100409-2634-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 99/99/9999 M0100409-2634-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 50 MG/5 ML VIAL 6/1/2009 99/99/9999 M0100409-2634-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 500 MG/50 ML VIA 6/1/2009 99/99/9999 M0159011-0441-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0442-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0442-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0444-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0445-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0445-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0445-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML VIAL 6/1/2009 99/99/9999 M0159011-0446-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 250 MG VIAL 6/1/2009 99/99/9999 M0100074-2332-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 3/31/2011 M0100074-2333-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/31/2011 M0100074-2333-26 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/1/2011 M0100074-2334-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 3/31/2011 M0100074-2414-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML VIAL 6/1/2009 3/31/2010 M0100406-3245-52 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 M0100409-1283-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 1 MG/ML SYRINGE 6/1/2009 99/99/9999 M0100409-1304-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 4 MG/ML SYRIN 6/1/2009 99/99/9999 M0100409-1312-30 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML SYRINGE 6/1/2009 99/99/9999 M0100409-2172-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 7/1/2011 M0100409-2172-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 9/30/2011 M0100409-2540-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 4 MG/ML AMP 6/1/2009 99/99/9999 M0100409-2552-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 1 MG/ML AMP 6/1/2009 99/99/9999 M0100409-3356-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 2 MG/ML AMP 6/1/2009 99/99/9999 M0100409-3365-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0100555-1117-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 8/31/2011 M0100555-1117-06 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 9/30/2011 M0100555-1117-07 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 6/30/2011 M0100574-2017-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 M0100641-0121-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0100641-2341-41 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0138779-0731-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 M0100641-0121-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0100409-2290-31 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML SYRNG 7/1/2015 99/99/9999 M0100641-0376-25 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0664-01 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0167457-0124-10 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0366-01 J1240 INJECTION, DIMENHYDRINATE, UP TO 50 MG DIMENHYDRINATE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0100641-2569-44 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100338-1073-02 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1075-02 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1077-02 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 7/1/2015 99/99/9999 M0100409-2025-20 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2025-54 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2344-01 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2344-02 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2344-88 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2346-32 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-2347-32 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-3724-32 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 7/1/2015 99/99/9999 M0100088-1206-32 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 M0100088-1208-06 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 M0100088-1208-69 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 9/30/2013 M0100088-1208-76 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 7/1/2010 M0100088-1209-26 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 M0100338-1005-02 J1265 INJECTION, DOPAMINE HCL DOPAMINE 200 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1005-03 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 500 ML 7/1/2015 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00338-1007-02 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1007-03 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 500 ML 7/1/2015 99/99/9999 M0100338-1009-02 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-5820-01 J1265 INJECTION, DOPAMINE HCL DOPAMINE 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-7808-22 J1265 INJECTION, DOPAMINE HCL DOPAMINE 200 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-7808-24 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 500 ML 7/1/2015 99/99/9999 M0100409-7809-22 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-7809-24 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 500 ML 7/1/2015 99/99/9999 M0100409-7810-22 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-9104-20 J1265 INJECTION, DOPAMINE HCL DOPAMINE 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100517-1305-25 J1265 INJECTION, DOPAMINE HCL DOPAMINE 160 MG/ML VIAL 7/1/2015 99/99/9999 M0100517-1905-25 J1265 INJECTION, DOPAMINE HCL DOPAMINE 80 MG/ML VIAL 7/1/2015 99/99/9999 M0158468-0126-01 J1270 INJECTION HECTOROL 2 MCG/ML VIAL 7/1/2015 99/99/9999 M0125682-0001-01 J1300 Eculizumab injection SOLIRIS 300 MG/30 ML VIAL 7/1/2015 99/99/9999 M0100173-0517-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 0.5 MG VIAL 7/7/2015 99/99/9999 M0100173-0519-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 1.5 MG VIAL 7/7/2015 99/99/9999 M0100006-3843-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM VIAL 7/1/2015 99/99/9999 M0100006-3845-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM ADD-VANTAGE VIAL 7/1/2015 99/99/9999 M0100409-6476-44 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG ADDVNT VL 7/1/2015 99/99/9999 M0100409-6482-01 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG VIAL 7/1/2015 99/99/9999 M0100046-0749-05 J1410 INJECTION, ESTROGEN CONJUGATED PREMARIN 25 MG VIAL 7/1/2015 99/99/9999 M0158406-0425-34 J1438 INJECTION, ETANERCEPT ENBREL 25 MG KIT 7/1/2015 99/99/9999 M0158406-0425-41 J1438 INJECTION, ETANERCEPT ENBREL 25 MG KIT 7/1/2015 99/99/9999 M0158406-0435-01 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SYRINGE 7/1/2015 99/99/9999 M0158406-0435-04 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SYRINGE 7/1/2015 99/99/9999 M0158406-0445-01 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SURECLICK SYR 7/1/2015 99/99/9999 M0158406-0445-04 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SURECLICK SYR 7/1/2015 99/99/9999 M0158406-0455-01 J1438 INJECTION, ETANERCEPT ENBREL 25 MG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0158406-0455-04 J1438 INJECTION, ETANERCEPT ENBREL 25 MG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0100517-0650-01 J1439 INJ FERRIC CARBOXYMALTOS 1MG INJECTAFER 750 MG/15 ML VIAL 1/1/2015 99/99/9999 M0155513-0209-01 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/0.8 ML SYR 1/1/2014 99/99/9999 M0155513-0209-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/0.8 ML SYR 1/1/2014 99/99/9999 M0155513-0546-01 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/1.6 ML VIAL 1/1/2014 99/99/9999 M0155513-0546-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/1.6 ML VIAL 1/1/2014 99/99/9999 M0155513-0924-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 300 MCG/0.5 ML SYR 1/1/2014 99/99/9999 M0155513-0530-01 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 300 MCG/ML VIAL 1/1/2014 99/99/9999 M0155513-0530-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 300 MCG/ML VIAL 1/1/2014 99/99/9999 M0100338-6045-37 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100338-6046-48 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4684-02 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-DEXT 400 MG/200 ML 7/1/2015 99/99/9999 M0100409-4684-23 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-DEXT 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4688-02 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100409-4688-23 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4688-28 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4688-34 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100703-1020-30 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100703-1029-30 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100006-3941-32 J1453 FOSAPREPITANT INJECTION EMEND 150 MG VIAL 11/15/2010 99/99/9999 M0100006-3884-32 J1453 FOSAPREPITANT INJECTION EMEND 115 MG VIAL 11/1/2009 7/31/2012 M0168135-0020-01 J1458 INJECTION, GALSULFASE, 1 MG NAGLAZYME 5 MG/5 ML VIAL 7/1/2015 99/99/9999 M0113533-0635-04 J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR GAMASTAN S-D VIAL 7/1/2015 99/99/9999 M0113533-0635-12 J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR GAMASTAN S-D VIAL 7/1/2015 99/99/9999 M0164208-8234-01 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 1/31/2015 M0164208-8234-02 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 99/99/9999 M0164208-8234-03 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 99/99/9999 M0161953-0005-02 J1566 INJECTION, IMMUNE GLOBULIN FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 M0100944-2655-03 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 G (IGA

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule44206-0417-06 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 6 GM VIAL 3/1/2010 99/99/9999 M0144206-0418-12 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 12 GM VIAL 3/1/2010 99/99/9999 M0164193-0250-50 J1566 INJECTION, IMMUNE GLOBULIN IVEEGAM EN 5 GM VIAL 3/1/2010 12/31/2010 M0100944-2700-02 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-03 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-04 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-05 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-06 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100004-6940-03 J1570 INJECTION, GANCICLOVIR SODIUM CYTOVENE 500 MG VIAL 7/1/2015 99/99/9999 M0161953-0005-02 J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 M0161953-0005-03 J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 11/15/2010 99/99/9999 M0161953-0003-01 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0003-02 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0003-03 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0003-04 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0004-01 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-02 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-03 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-04 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-05 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0100338-0503-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 80 MG/100 ML 7/1/2015 99/99/9999 M0100338-0505-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISO GENTAMICIN 100 MG/100 ML 7/1/2015 99/99/9999 M0100338-0507-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 60 MG/50 ML 7/1/2015 99/99/9999 M0100338-0507-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISO GENTAMICIN 120 MG/100 ML 7/1/2015 99/99/9999 M0100338-0509-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 80 MG/50 ML 7/1/2015 99/99/9999 M0100338-0511-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 100 MG/50 ML 7/1/2015 99/99/9999 M0100409-1207-03 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100409-7879-13 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 60 MG/NS 50 ML PB 7/1/2015 99/99/9999 M0100409-7883-13 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 50 ML PB 7/1/2015 99/99/9999 M0100409-7884-23 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 100 ML PB 7/1/2015 99/99/9999 M0100409-7889-23 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 100 MG/NS 100 ML 7/1/2015 99/99/9999 M0163323-0010-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0010-20 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 40 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0173-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN PED 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0513-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100002-8031-01 J1610 INJECTION,GLUCAGON GLUCAGON 1 MG EMERGENCY KIT 7/1/2015 99/99/9999 M0100169-7065-15 J1610 INJECTION,GLUCAGON GLUCAGEN 1 MG HYPOKIT 7/1/2015 99/99/9999 M0155390-0004-01 J1610 INJECTION,GLUCAGON GLUCAGEN DIAGNOSTIC 1 MG VIAL 7/1/2015 99/99/9999 M0155390-0004-10 J1610 INJECTION,GLUCAGON GLUCAGEN DIAGNOSTIC 1 MG VIAL 7/1/2015 99/99/9999 M0155390-0250-10 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 9/30/2011 M0163323-0318-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 M0163323-0319-04 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 99/99/9999 M0166758-0035-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 M0166758-0036-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 99/99/9999 M0166758-0037-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 12/31/2010 M0100703-7973-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 1/1/2010 99/99/9999 M0163323-0317-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/2010 99/99/9999 M0100703-7871-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 1/1/2010 8/31/2010 M0100703-7891-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/2010 12/31/2010 M0100703-7971-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 M0110019-0053-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 6/28/2010 M0160505-0764-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 99/99/9999 M0100004-0239-09 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 1 MG/ML VIAL 6/1/2009 7/31/2010 M0100004-0240-09 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 4 MG/4 ML VIAL 6/1/2009 11/30/2011 M0100004-0242-08 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 0.1 MG/ML VIAL 6/1/2009 3/31/2010 M0100703-7045-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0474-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0474-10 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0474-91 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100045-0253-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/2011 M0100045-0253-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/2011 M0100045-0254-14 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 100 AMPUL 3/1/2008 5/31/2011 M0100703-7011-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0100703-7013-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0100703-7021-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00703-7023-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0155390-0412-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/2011 M0155390-0412-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/2011 M0155390-0413-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/2011 M0155390-0413-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/2011 M0160505-0702-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0160505-0703-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0469-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0469-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0471-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0471-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0150458-0253-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 11/10/2010 99/99/9999 M0167386-0701-54 J1640 INJECTION, HEMIN PANHEMATIN 313 MG VIAL 7/1/2015 9/30/2015 M0100264-9567-10 J1644 INJECTION, HEPARIN HEPARIN-D5W 20,000 UNIT/500 ML 7/1/2015 99/99/9999 M0100264-9577-10 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/500 ML 7/1/2015 99/99/9999 M0100264-9587-20 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/250 ML 7/1/2015 99/99/9999 M0100264-9872-10 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 7/1/2015 99/99/9999 M0100338-0431-03 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 7/1/2015 99/99/9999 M0100338-0433-04 J1644 INJECTION, HEPARIN HEPARIN-NS 2,000 UNIT/1,000 ML 7/1/2015 99/99/9999 M0100409-1316-32 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/0.5 ML 7/1/2015 99/99/9999 M0100409-7620-03 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 7/1/2015 99/99/9999 M0100409-7620-59 J1644 INJECTION, HEPARIN HEPARIN-NS 2,000 UNIT/1,000 ML 7/1/2015 99/99/9999 M0100409-7650-62 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 25,000 UNITS/250 7/1/2015 99/99/9999 M0100409-7651-03 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 25,000 UNITS/500 7/1/2015 99/99/9999 M0100409-7651-62 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 12,500 UNITS/250 7/1/2015 99/99/9999 M0100409-7793-62 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/250 ML 7/1/2015 99/99/9999 M0100409-7794-62 J1644 INJECTION, HEPARIN HEPARIN-D5W 12,500 UNIT/250 ML 7/1/2015 99/99/9999 M0163323-0047-10 J1644 INJECTION, HEPARIN HEPARIN 50,000 UNITS/10 ML VL 7/1/2015 99/99/9999 M0163323-0262-01 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/ML VIAL 7/1/2015 99/99/9999 M0163323-0276-02 J1644 INJECTION, HEPARIN HEPARIN 2,000 UNIT/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0540-01 J1644 INJECTION, HEPARIN HEPARIN SOD 1,000 UNIT/ML VIAL 7/1/2015 99/99/9999 M0163323-0540-11 J1644 INJECTION, HEPARIN HEPARIN 10,000 UNIT/10 ML VIAL 7/1/2015 99/99/9999 M0163323-0540-31 J1644 INJECTION, HEPARIN HEPARIN 30,000 UNIT/30 ML VIAL 7/1/2015 99/99/9999 M0163323-0542-01 J1644 INJECTION, HEPARIN HEPARIN SOD 10,000 UNIT/ML VL 7/1/2015 99/99/9999 M0163323-0542-07 J1644 INJECTION, HEPARIN HEPARIN 50,000 UNITS/5 ML VIAL 7/1/2015 99/99/9999 M0163323-0915-01 J1644 INJECTION, HEPARIN HEPARIN SOD 20,000 UNIT/ML VL 7/1/2015 99/99/9999 M0162856-0101-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 10,000 UNITS/ML SYRING 7/1/2015 99/99/9999 M0162856-0125-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 12,500 UNITS/0.5 ML 7/1/2015 99/99/9999 M0162856-0150-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 15,000 UNITS/0.6 ML 7/1/2015 99/99/9999 M0162856-0180-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 18,000 UNITS/0.72 ML 7/1/2015 99/99/9999 M0162856-0250-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 2,500 UNITS/0.2 ML SYR 7/1/2015 99/99/9999 M0162856-0251-01 J1645 INJECTION, DALTEPARIN NA FRAGMIN 25,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0162856-0500-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 5,000 UNITS/0.2 ML SYR 7/1/2015 99/99/9999 M0162856-0750-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 7,500 UNITS/0.3 ML SYR 7/1/2015 99/99/9999 M0100075-0620-40 J1650 ENOXAPARIN SODIUM LOVENOX 40 MG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0621-60 J1650 ENOXAPARIN SODIUM LOVENOX 60 MG/0.6 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0622-80 J1650 ENOXAPARIN SODIUM LOVENOX 80 MG/0.8 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0623-00 J1650 ENOXAPARIN SODIUM LOVENOX 100 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100075-0624-30 J1650 ENOXAPARIN SODIUM LOVENOX 30 MG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0626-03 J1650 ENOXAPARIN SODIUM LOVENOX 300 MG/3 ML VIAL 7/1/2015 99/99/9999 M0100075-2912-01 J1650 ENOXAPARIN SODIUM LOVENOX 120 MG/0.8 ML SYRINGE 7/1/2015 99/99/9999 M0100075-2915-01 J1650 ENOXAPARIN SODIUM LOVENOX 150 MG/ML SYRINGE 7/1/2015 99/99/9999 M0113533-0634-02 J1670 INJECTION, TETANUS IMMUNE GLOBULIN, HUMA HYPERTET S-D 250 UNITS SYRINGE 7/1/2015 99/99/9999 M0100009-0825-01 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 100 MG VIAL 7/1/2015 99/99/9999 M0164011-0243-01 J1725 HYDROXYPROGESTERONE CAPROATE MAKENA 1,250 MG/5 ML VIAL 1/1/2012 99/99/9999 M0100517-0750-01 J1725 HYDROXYPROGESTERONE CAPROATE PROGESTERONE OIL 50 MG/ML VL 1/1/2012 99/99/9999 M0100009-3794-01 J1742 INJECTION, IBUTILIDE FUMARATE CORVERT 1 MG/10 ML VIAL 7/1/2015 99/99/9999 M0154092-0700-01 J1743 Idursulfase injection ELAPRASE 6 MG/3 ML VIAL 7/1/2015 99/99/9999 M0157894-0030-01 J1745 INJECTION, INFLIZIMAB REMICADE 100 MG VIAL 7/1/2015 99/99/9999 M0152544-0931-02 J1750 INJECTION, IRON DEXTRAN INFED 100 MG/2 ML VIAL 1/1/2010 99/99/9999 M0149230-0534-10 J1750 INJECTION, IRON DEXTRAN VENOFER 100 MG/5 ML VIAL 1/1/2010 99/99/9999 M0100517-0234-10 J1750 INJECTION, IRON DEXTRAN DEXFERRUM 100 MG/2 ML VIAL 1/1/2010 3/31/2014 M0100517-2310-05 J1756 INJECTION, IRON SUCROSE VENOFER 200 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100517-2340-10 J1756 INJECTION, IRON SUCROSE VENOFER 100 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100517-2340-25 J1756 INJECTION, IRON SUCROSE VENOFER 100 MG/5 ML VIAL 7/1/2015 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule49230-0530-10 J1756 INJECTION, IRON SUCROSE VENOFER 50 MG/2.5 ML VIAL 7/1/2015 99/99/9999 M0149230-0530-25 J1756 INJECTION, IRON SUCROSE VENOFER 50 MG/2.5 ML VIAL 7/1/2015 99/99/9999 M0149230-0534-10 J1756 INJECTION, IRON SUCROSE VENOFER 100 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100409-1187-01 J1790 INJECTION, DROPERIDOL, UP TO 5 MG DROPERIDOL 2.5 MG/ML AMPUL 7/1/2015 99/99/9999 M0100517-9702-25 J1790 INJECTION, DROPERIDOL, UP TO 5 MG DROPERIDOL 2.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100781-3777-95 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG PROPRANOLOL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0604-01 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG PROPRANOLOL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100002-7511-01 J1815 INJECTION, INSULIN HUMALOG MIX 75-25 VIAL 7/1/2015 99/99/9999 M0100002-7512-01 J1815 INJECTION, INSULIN HUMALOG MIX 50-50 VIAL 7/1/2015 99/99/9999 M0100002-7516-59 J1815 INJECTION, INSULIN HUMALOG 100 UNITS/ML CARTRIDGE 7/1/2015 99/99/9999 M0100002-8215-01 J1815 INJECTION, INSULIN HUMULIN R 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100002-8315-01 J1815 INJECTION, INSULIN HUMULIN N 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100002-8501-01 J1815 INJECTION, INSULIN HUMULIN R 500 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100002-8715-01 J1815 INJECTION, INSULIN HUMULIN 70-30 VIAL 7/1/2015 99/99/9999 M0100002-8730-59 J1815 INJECTION, INSULIN HUMULIN N 100 UNITS/ML PEN 7/1/2015 10/31/2015 M0100002-8770-59 J1815 INJECTION, INSULIN HUMULIN 70-30 PEN 7/1/2015 10/31/2015 M0100088-2220-33 J1815 INJECTION, INSULIN LANTUS 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100088-2220-60 J1815 INJECTION, INSULIN LANTUS SOLOSTAR 100 UNITS/ML 7/1/2015 99/99/9999 M0100169-1833-11 J1815 INJECTION, INSULIN NOVOLIN R 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100169-1834-11 J1815 INJECTION, INSULIN NOVOLIN N 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100169-1837-11 J1815 INJECTION, INSULIN NOVOLIN 70-30 100 UNIT/ML VIAL 7/1/2015 99/99/9999 M0100169-3303-12 J1815 INJECTION, INSULIN NOVOLOG 100 UNIT/ML CARTRIDGE 7/1/2015 99/99/9999 M0100169-3685-12 J1815 INJECTION, INSULIN NOVOLOG MIX 70-30 VIAL 7/1/2015 99/99/9999 M0100169-3696-19 J1815 INJECTION, INSULIN NOVOLOG MIX 70-30 FLEXPEN SYRN 7/1/2015 99/99/9999 M0100169-6339-10 J1815 INJECTION, INSULIN NOVOLOG 100 UNITS/ML FLEXPEN 7/1/2015 99/99/9999 M0100002-7510-01 J1817 INSULIN ADMIN THROUGH DME HUMALOG 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100088-2500-33 J1817 INSULIN ADMIN THROUGH DME APIDRA 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100169-7501-11 J1817 INSULIN ADMIN THROUGH DME NOVOLOG 100 UNIT/ML VIAL 7/1/2015 99/99/9999 M0163323-0359-03 J1840 INJECTION, KANAMYCIN SULFATE, UP TO 500 KANAMYCIN 1 GM/3 ML VIAL 7/1/2015 99/99/9999 M0110019-0030-12 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 5/15/2009 5/31/2013 M0100409-2287-21 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML ISECURE SYR 3/1/2008 4/1/2012 M0100409-2287-22 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2ML ISECURE 3/1/2008 10/1/2011 M0100409-2287-31 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 99/99/9999 M0100409-2287-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 99/99/9999 M0100409-2288-21 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML ISECURE SYR 3/1/2008 12/31/2012 M0100409-2288-31 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML CARPUJECT 3/1/2008 99/99/9999 M0100409-3793-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3793-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3795-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3795-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3795-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 9/30/2011 M0100409-3796-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 M0100409-3796-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 M0100409-3796-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 7/1/2011 M0110019-0021-09 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML SYRINGE 3/1/2008 3/31/2010 M0110019-0022-09 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML SYRINGE 3/1/2008 3/31/2010 M0110019-0022-32 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC IM 30 MG/ML SYRING 3/1/2008 3/31/2010 M0110019-0029-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 10/31/2013 M0110019-0030-03 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 5/31/2013 M0110019-0030-04 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 8/31/2013 M0155390-0480-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 3/31/2013 M0155390-0481-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 11/30/2013 M0155390-0481-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 3/31/2013 M0155390-0481-10 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 300 MG/10 ML VIAL 3/1/2008 3/31/2014 M0163323-0161-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0162-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0162-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 M0164679-0757-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 3/31/2015 M0164679-0757-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 3/31/2015 M0164679-0758-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 4/30/2015 M0164679-0758-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 2/28/2015 M0164679-0758-04 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 3/31/2015 M0164679-0758-05 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 3/31/2010 M0164679-0758-06 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 2/28/2015 M0100074-2287-54 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 9/30/2014 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00003-0293-05 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KENALOG-40 40 MG/ML VIAL 3/1/2008 99/99/9999 M0158468-0070-01 J1931 LARONIDASE INJECTION ALDURAZYME 2.9 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100409-1639-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 10 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-6102-02 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100409-6102-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 40 MG/4 ML VIAL 7/1/2015 99/99/9999 M0100409-6102-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 100 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-9631-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 10 MG/ML SYRINGE 7/1/2015 99/99/9999 M0163323-0280-02 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0280-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 40 MG/4 ML VIAL 7/1/2015 99/99/9999 M0163323-0280-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 100 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100074-3663-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 11.25 MG 3MO KIT 1/1/2012 99/99/9999 M0100074-3346-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 22.5 MG 3MO KIT 1/1/2012 99/99/9999 M0100074-3641-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 3.75 MG KIT 1/1/2012 99/99/9999 M0139822-4000-01 J1953 LEVETIRACETAM INJECTION LEVETIRACETAM 500 MG/5 ML VIAL 7/1/2015 99/99/9999 M0150474-0002-63 J1953 LEVETIRACETAM INJECTION KEPPRA 500 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100703-0404-02 J1955 LEVOCARNITINE LEVOCARNITINE 200 MG/ML VIAL 7/1/2015 99/99/9999 M0100703-0405-02 J1955 LEVOCARNITINE LEVOCARNITINE 200 MG/ML VIAL 7/1/2015 99/99/9999 M0154482-0147-01 J1955 LEVOCARNITINE CARNITOR 1 GM/5 ML VIAL 7/1/2015 99/99/9999 M0100264-9594-10 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100264-9594-20 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100264-9598-20 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 7/1/2015 99/99/9999 M0100338-0409-03 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100338-0411-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 7/1/2015 99/99/9999 M0100409-1323-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% SYRINGE 7/1/2015 99/99/9999 M0100409-2066-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100409-4056-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1.5% AMPUL 7/1/2015 99/99/9999 M0100409-4270-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4275-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 0.5% VIAL 7/1/2015 99/99/9999 M0100409-4276-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4276-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4277-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100409-4277-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100409-4278-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 0.5% VIAL 7/1/2015 99/99/9999 M0100409-4279-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4282-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% AMPUL 7/1/2015 99/99/9999 M0100409-4282-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% AMPUL 7/1/2015 99/99/9999 M0100409-4283-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 4% AMPUL 7/1/2015 99/99/9999 M0100409-4713-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% AMPUL 7/1/2015 99/99/9999 M0100409-4713-32 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% AMPUL 7/1/2015 99/99/9999 M0100409-4776-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1.5% AMPUL 7/1/2015 99/99/9999 M0100409-4903-34 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% ABBOJECT 7/1/2015 99/99/9999 M0100409-4904-34 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% ABBOJECT 7/1/2015 99/99/9999 M0100409-7931-32 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100409-9137-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% SYRINGE 7/1/2015 99/99/9999 M0163323-0201-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0163323-0201-10 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0163323-0202-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0163323-0208-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100009-0555-01 J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG LINCOCIN 300 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0555-02 J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG LINCOCIN 300 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-5137-01 J2020 INJECTION ZYVOX 200 MG/100 ML IV SOLN 7/1/2015 99/99/9999 M0100009-5140-01 J2020 INJECTION ZYVOX 600 MG/300 ML IV SOLN 7/1/2015 99/99/9999 M0100409-1539-31 J2060 INJECTION, LORAZEPAM LORAZEPAM 4 MG/ML CARPUJECT 7/1/2015 99/99/9999 M0100409-1985-30 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML CARPUJECT 7/1/2015 99/99/9999 M0100409-6778-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-6779-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 4 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-6780-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-6781-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 4 MG/ML VIAL 7/1/2015 99/99/9999 M0117478-0040-01 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-4031-01 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL 25% VIAL 7/1/2015 99/99/9999 M0163323-0024-25 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL 25% VIAL 7/1/2015 99/99/9999 M0115054-1040-05 J2170 INJECTION, MECASERMIN, 1 MG INCRELEX 40 MG/4 ML VIAL 7/1/2015 99/99/9999 M0100409-1176-30 J2175 INJECTION, MEPERIDINE DEMEROL 25 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-1178-30 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-1179-30 J2175 INJECTION, MEPERIDINE DEMEROL 75 MG/ML SYRINGE 7/1/2015 99/99/9999 M01

  • Updated 8.11.15

    NDC HCPCS HCPCS Description NDC DescriptionEffective

    Date End DateX-Over

    OnlyFee

    Schedule00409-1180-69 J2175 INJECTION, MEPERIDINE DEMEROL 100 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-1181-30 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1201-20 J2175 INJECTION, MEPERIDINE DEMEROL 100 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1203-01 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1253-01 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1254-01 J2175 INJECTION, MEPERIDINE DEMEROL 75 MG/1.5 ML AMPUL 7/1/2015 99/99/9999 M0100409-1255-02 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1256-01 J2175 INJECTION, MEPERIDINE DEMEROL 100 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-6030-04 J2175 INJECTION, MEPERIDINE MEPERIDINE 10 MG/ML CARTRDGE 7/1/2015 99/99/9999 M0100310-0321-30 J2185 MEROPENEM INJECTION MERREM IV 1 GM VIAL 7/1/2015 99/99/9999 M0100310-0325-20 J2185 MEROPENEM INJECTION MERREM IV 500 MG VIAL 7/1/2015 99/99/9999 M0100469-3211-10 J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG MYCAMINE 100 MG VIAL 7/1/2015 99/99/9999 M0100469-3250-10 J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG MYCAMINE 50 MG VIAL 7/1/2015 99/99/9999 M0100409-2305-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2305-50 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2306-62 J2250 MIDAZOLAM HCL MIDAZOLAM 2 MG/2 ML CARPUJECT 7/1/2015 99/99/9999 M0100409-2307-60 J2250 MIDAZOLAM HCL MIDAZOLAM 5 MG/ML CARPUJECT 7/1/2015 99/99/9999 M0100409-2308-01 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2308-02 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2308-49 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2308-50 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100409-2587-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-2587-53 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-2596-03 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2596-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2596-52 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2596-53 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0411-10 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/10 ML VIAL 7/1/2015 99/99/9999 M0163323-0411-12 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 2 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0411-25 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/5 ML VIAL 7/1/2015 99/99/9999 M0163323-0412-02 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0412-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0412-10 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0412-25 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100338-6010-48 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 20 MG/100 ML 7/1/2015 99/99/9999 M0100338-6011-37 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 40 MG/200 ML 7/1/2015 99/99/9999 M0100409-2776-02 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 40 MG/200 ML 7/1/2015 99/99/9999 M0100409-2776-23 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 20 MG/100 ML 7/1/2015 99/99/9999 M0160505-0718-00 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 10 MG/10 ML VL 7/1/2015 99/99/9999 M0160505-0718-01 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 20 MG/20 ML VL 7/1/2015 99/99/9999 M0163323-0617-10 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 10 MG/10 ML VL 7/1/2015 99/99/9999 M0163323-0617-20 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 20 MG/20 ML VL 7/1/2015 99/99/9999 M0163323-0617-50 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 50 MG/50 ML VL 7/1/2015 99/99/9999 M0100409-3815-12 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML VIAL P-F 7/1/2015 99/99/9999 M0100409-6177-14 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE SULFATE 25 MG/ML VL 7/1/2015 99/99/9999 M0100409-6179-14 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE SULFATE 25 MG/ML VL 7/1/2015 99/99/9999 M0100548-1911-25 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML SYRINGE 7/1/2015 8/31/2015 M0100409-1463-01 J2300 NALBUPHINE HCL NALBUPHINE 10 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1464-01 J2300 NALBUPHINE HCL NALBUPHINE 100 MG/10 ML VIAL