physicians injectable drug list - chfs.ky.gov · brand name: generic name. strength: effective...
TRANSCRIPT
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsA9606 50419020801 XOFIGO RADIUM-223 DICHLORIDE 1000KBQ/ML 2015-01-01 2299-12-31 1000 1 KBQ EA
A9699 50419020801 XOFIGO RADIUM-223 DICHLORIDE 1000KBQ/ML 2014-11-25 2014-12-31 1 1 KBQ 1
J0135 54868482200 HUMIRA ADALIMUMAB 40MG/0.8ML 2007-07-01 2009-12-15 25 20 MG EA
J0135 00074379902 HUMIRA ADALIMUMAB 40MG/0.8ML 2007-07-01 2299-12-31 25 20 MG EA
J0135 00074379903 HUMIRA PEDIATRIC ADALIMUMAB 40MG/0.8ML 2014-10-01 2299-12-31 25 20 MG EA
J0135 00074379906 HUMIRA PEDIATRIC ADALIMUMAB 40MG/0.8ML 2014-10-01 2299-12-31 25 20 MG EA
J0135 00074433902 HUMIRA ADALIMUMAB 40MG/0.8ML 2007-07-01 2299-12-31 25 20 MG EA
J0135 00074433906 HUMIRA ADALIMUMAB 40MG/0.8ML 2007-07-01 2299-12-31 25 20 MG EA
J0135 00074433907 HUMIRA ADALIMUMAB 40MG/0.8ML 2009-03-19 2299-12-31 25 20 MG EA
J0135 00074433971 HUMIRA ADALIMUMAB 40MG/0.8ML 2015-04-15 2299-12-31 25 20 MG EA
J0135 00074634702 HUMIRA ADALIMUMAB 10MG/0.2ML 2014-10-15 2299-12-31 2.5 20 MG EA
J0135 00074937402 HUMIRA ADALIMUMAB 20MG/0.4ML 2008-02-22 2299-12-31 2.5 20 MG EA
J0171 00143998490 EPINEPHRINE EPINEPHRINE 1 MG/ML 2012-01-01 2012-05-13 10 0.1 MG ML
J0171 63739045605 EPINEPHRINE EPINEPHRINE 0.1 MG/ML 2012-01-01 2013-04-30 10 0.1 MG ML
J0171 63739045621 EPINEPHRINE EPINEPHRINE 0.1 MG/ML 2012-01-01 2013-04-30 10 0.1 MG ML
J0171 00548906100 EPINEPHRINE EPINEPHRINE 1 MG/ML 2012-01-01 2013-09-13 10 0.1 MG ML
J0171 00548331600 EPINEPHRINE EPINEPHRINE 0.1 MG/ML 2012-01-01 2013-10-05 10 0.1 MG ML
J0171 42023010101 ADRENALIN CHLORIDE EPINEPHRINE 1 MG/ML 2012-01-01 2015-07-07 10 0.1 MG ML
J0171 42023010110 ADRENALIN CHLORIDE EPINEPHRINE 1 MG/ML 2012-01-01 2015-07-07 10 0.1 MG ML
J0171 42023012225 ADRENALIN CHLORIDE EPINEPHRINE 1 MG/ML(1) 2012-01-01 2015-07-07 10 0.1 MG ML
J0171 00517113005 EPINEPHRINE EPINEPHRINE 1 MG/ML 2012-01-01 2016-04-20 10 0.1 MG ML
J0171 00409490118 EPINEPHRINE EPINEPHRINE 0.1 MG/ML 2012-01-01 2299-12-31 1 0.1 MG ML
J0171 00409492134 EPINEPHRINE EPINEPHRINE 0.1 MG/ML 2012-01-01 2299-12-31 1 0.1 MG ML
J0171 00409724101 EPINEPHRINE EPINEPHRINE 1 MG/ML(1) 2012-01-01 2299-12-31 10 0.1 MG ML
J0171 00409724125 EPINEPHRINE EPINEPHRINE 1 MG/ML(1) 2014-03-01 2299-12-31 10 0.1 MG ML
J0171 00409724161 EPINEPHRINE EPINEPHRINE 1 MG/ML(1) 2012-01-01 2299-12-31 10 0.1 MG ML
J0171 42023015925 ADRENALIN EPINEPHRINE 1 MG/ML 2013-08-01 2299-12-31 10 0.1 MG ML
J0171 42023016801 ADRENALIN EPINEPHRINE 1 MG/ML 2014-04-01 2299-12-31 10 0.1 MG ML
J0171 76329331601 EPINEPHRINE EPINEPHRINE 0.1 MG/ML 2012-05-10 2299-12-31 1 0.1 MG ML
J0171 76329906100 EPINEPHRINE EPINEPHRINE 1 MG/ML 2012-09-11 2299-12-31 10 0.1 MG ML
J0178 61755000502 EYLEA AFLIBERCEPT 2MG/0.05ML 2013-01-01 2299-12-31 40 1 MG ML
J0180 58468004001 FABRAZYME AGALSIDASE BETA 35 MG 2012-07-01 2299-12-31 35 1 MG EA
J0180 58468004101 FABRAZYME AGALSIDASE BETA 5 MG 2012-07-01 2299-12-31 5 1 MG EA
J0202 58468020001 LEMTRADA ALEMTUZUMAB 12 MG/1.2 ML 2016-01-01 2299-12-31 1 10 MG ML
J0207 58178001703 ETHYOL AMIFOSTINE CRYSTALLINE 500 MG 2007-07-01 2012-03-31 1 500 MG EA
J0207 62756058140 AMIFOSTINE AMIFOSTINE CRYSTALLINE 500 MG 2008-03-26 2013-02-28 1 500 MG EA
J0207 62756058142 AMIFOSTINE AMIFOSTINE CRYSTALLINE 500 MG 2008-03-26 2013-02-28 1 500 MG EA
J0207 58178001701 ETHYOL AMIFOSTINE CRYSTALLINE 500 MG 2007-07-01 2013-03-31 1 500 MG EA
J0207 47335058140 AMIFOSTINE AMIFOSTINE CRYSTALLINE 500 MG 2011-02-08 2299-12-31 1 500 MG EA
J0207 47335058142 AMIFOSTINE AMIFOSTINE CRYSTALLINE 500 MG 2011-02-08 2299-12-31 1 500 MG EA
J0207 55390030803 AMIFOSTINE AMIFOSTINE CRYSTALLINE 500 MG 2008-04-08 2299-12-31 1 500 MG EA
J0215 59627002104 AMEVIVE ALEFACEPT 15 MG 2007-07-01 2009-02-14 30 0.5 MG EA
J0215 59627002103 AMEVIVE ALEFACEPT 15 MG 2007-07-01 2009-08-05 30 0.5 MG EA
PHYSICIANS INJECTABLE DRUG LISTEFFECTIVE
April 1, 2016
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ0215 00469002103 AMEVIVE ALEFACEPT 15 MG 2008-02-28 2012-11-16 30 0.5 MG EA
J0215 00469002104 AMEVIVE ALEFACEPT 15 MG 2007-12-31 2012-11-16 30 0.5 MG EA
J0220 58468015001 MYOZYME ALGLUCOSIDASE ALFA 50 MG 2012-01-01 2299-12-31 0.1 10 MG EA
J0221 58468016001 LUMIZYME ALGLUCOSIDASE ALFA 50 MG 2012-01-01 2299-12-31 5 10 MG EA
J0221 58468016002 LUMIZYME ALGLUCOSIDASE ALFA 50 MG 2014-02-01 2299-12-31 5 10 MG EA
J0256 13533070011 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR 1000 MG 2012-11-07 2013-03-14 100 10 MG EA
J0256 00944281201 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR 500 MG 2012-01-01 2013-03-31 50 10 MG EA
J0256 13533060130 PROLASTIN ALPHA-1-PROTEINASE INHIBITOR 500 MG 2012-01-01 2013-12-17 50 10 MG EA
J0256 13533060135 PROLASTIN ALPHA-1-PROTEINASE INHIBITOR 1,000 MG 2012-01-01 2013-12-17 100 10 MG EA
J0256 00944282202 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR 1,000 MG 2012-01-01 2014-02-28 100 10 MG EA
J0256 00053720102 ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR 1,000 MG 2012-01-01 2299-12-31 100 10 MG EA
J0256 00944280201 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR 500 MG 2012-01-01 2299-12-31 50 10 MG EA
J0256 00944280202 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR 1,000 MG 2012-01-01 2299-12-31 100 10 MG EA
J0256 00944281401 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR 500 MG 2014-05-01 2299-12-31 50 10 MG EA
J0256 00944281501 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR 1000 MG 2014-05-01 2299-12-31 100 10 MG EA
J0256 13533070001 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR 1,000 MG 2012-01-01 2299-12-31 100 10 MG EA
J0256 13533070002 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR 1,000 MG 2012-07-11 2299-12-31 100 10 MG EA
J0256 13533070101 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR 1000 MG 2015-08-04 2299-12-31 100 10 MG EA
J0256 13533070211 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR 1000 MG 2015-08-04 2299-12-31 100 10 MG EA
J0257 00944288401 GLASSIA ALPHA-1-PROTEINASE INHIBITOR 1 G/50 ML 2012-01-01 2299-12-31 2 10 MG EA
J0401 59148001870 ABILIFY MAINTENA ARIPIPRAZOLE 300 MG 2014-01-30 2299-12-31 300 1 MG EA
J0401 59148001871 ABILIFY MAINTENA ARIPIPRAZOLE 300 MG 2014-01-01 2299-12-31 300 1 MG EA
J0401 59148001970 ABILIFY MAINTENA ARIPIPRAZOLE 400 MG 2014-01-30 2299-12-31 400 1 MG EA
J0401 59148001971 ABILIFY MAINTENA ARIPIPRAZOLE 400 MG 2014-01-01 2299-12-31 400 1 MG EA
J0401 59148004580 ABILIFY MAINTENA ARIPIPRAZOLE 300 MG 2015-01-09 2299-12-31 300 1 MG EA
J0401 59148007280 ABILIFY MAINTENA ARIPIPRAZOLE 400 MG 2015-01-09 2299-12-31 400 1 MG EA
J0475 45945015101 GABLOFEN BACLOFEN 50 MCG/ML 2010-12-30 2013-02-27 0.005 10 MG ML
J0475 45945015501 GABLOFEN BACLOFEN 10000/20ML 2013-01-21 2299-12-31 0.05 10 MG ML
J0475 45945015502 GABLOFEN BACLOFEN 10000/20ML 2011-02-08 2299-12-31 0.05 10 MG ML
J0475 45945015601 GABLOFEN BACLOFEN 20K MCG/20 2013-01-21 2299-12-31 0.1 10 MG ML
J0475 45945015602 GABLOFEN BACLOFEN 20K MCG/20 2012-06-25 2299-12-31 0.1 10 MG ML
J0475 45945015701 GABLOFEN BACLOFEN 40000/20ML 2013-01-21 2299-12-31 0.2 10 MG ML
J0475 45945015702 GABLOFEN BACLOFEN 40000/20ML 2011-02-08 2299-12-31 0.2 10 MG ML
J0475 58281056001 LIORESAL INTRATHECAL BACLOFEN 10MG/20ML 2007-07-01 2299-12-31 0.05 10 MG ML
J0475 58281056002 LIORESAL INTRATHECAL BACLOFEN 10MG/20ML 2007-07-01 2299-12-31 0.05 10 MG ML
J0475 58281056102 LIORESAL INTRATHECAL BACLOFEN 10MG/5ML 2007-07-01 2299-12-31 0.2 10 MG ML
J0475 58281056201 LIORESAL INTRATHECAL BACLOFEN 0.05MG/ML 2007-07-01 2299-12-31 0.005 10 MG ML
J0475 58281056301 LIORESAL INTRATHECAL BACLOFEN 40MG/20ML 2007-07-01 2299-12-31 0.2 10 MG ML
J0475 58281056302 LIORESAL INTRATHECAL BACLOFEN 40MG/20ML 2007-07-01 2299-12-31 0.2 10 MG ML
J0476 45945015101 GABLOFEN BACLOFEN 50 MCG/ML 2013-02-28 2299-12-31 1 50 MCG ML
J0480 00078033184 SIMULECT BASILIXIMAB 20 MG 2007-07-01 2299-12-31 1 20 MG EA
J0480 00078039361 SIMULECT BASILIXIMAB 10 MG 2007-07-01 2299-12-31 0.5 20 MG EA
J0485 00003037113 NULOJIX BELATACEPT 250 MG 2013-01-01 2299-12-31 250 1 MG EA
J0490 49401010101 BENLYSTA BELIMUMAB 120 MG 2012-01-01 2299-12-31 12 10 MG EA
J0490 49401010201 BENLYSTA BELIMUMAB 400 MG 2012-01-01 2299-12-31 40 10 MG EA
J0530 61570014410 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 900-300/2 2007-07-01 2008-08-15 4.5 100,000 UNITS ML
J0530 61570013910 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 600000/ML 2007-07-01 2008-08-22 6 100,000 UNITS ML
J0530 61570014310 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 900-300/2 2007-07-01 2008-08-22 4.5 100,000 UNITS ML
J0540 61570014010 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2007-07-01 2008-08-15 6 100,000 UNITS ML
J0540 61570014110 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2007-07-01 2008-08-15 6 100,000 UNITS ML
J0540 60793060002 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2007-07-01 2009-12-23 6 100,000 UNITS ML
J0540 60793060010 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2007-07-01 2009-12-31 6 100,000 UNITS ML
J0540 60793060110 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2007-07-01 2009-12-31 6 100,000 UNITS ML
J0550 61570014210 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 2.4MM/4ML 2007-07-01 2008-10-11 6 100,000 UNITS ML
J0558 60793013001 PENICILLIN G PROCAINE PENICILLIN G PROCAINE 600000/ML 2015-06-29 2299-12-31 6 100,000 UNITS ML
J0558 60793013010 PENICILLIN G PROCAINE PENICILLIN G 600,000 UNITS/ML 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0558 60793013101 PENICILLIN G PROCAINE PENICILLIN G PROCAINE 1.2MM/2 ML 2015-07-02 2299-12-31 6 100,000 UNITS ML
J0558 60793013110 PENICILLIN G PROCAINE PEN G 1.2 MILLION UNITS/2ML 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0558 60793060010 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2011-01-01 2299-12-31 6 100,000 UNITS ML
2
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ0558 60793070001 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2 ML 2015-02-12 2299-12-31 6 100,000 UNITS ML
J0558 60793060110 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0558 60793060202 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 900-300/2 2014-10-31 2299-12-31 4.5 100,000 UNITS ML
J0558 60793060210 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 900-300/2 2011-01-01 2299-12-31 4.5 100,000 UNITS ML
J0559 60793060010 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2010-01-01 2010-12-31 240 2500 UNITS ML
J0559 60793060110 BICILLIN C-R PEN G BENZ/PEN G PROCAINE 1.2MM/2ML 2010-01-01 2010-12-31 240 2500 UNITS ML
J0560 61570014610 BICILLIN L-A PENICILLIN G BENZATHINE 600,000 UNITS 2007-07-01 2007-11-21 6 100,000 UNITS ML
J0560 60793070010 BICILLIN L-A PENICILLIN G BENZATHINE 600,000 UNITS 2007-07-01 2010-12-31 6 100,000 UNITS ML
J0561 54868246600 BICILLIN L-A PENICILLIN G BENZATHINE 2.4MM/4ML 2011-02-23 2011-12-15 6 100,000 UNITS ML
J0561 60793070001 BICILLIN L-A PENICILLIN G BENZATHINE 600000/ML 2015-06-30 2299-12-31 6 100,000 UNITS ML
J0561 60793070010 BICILLIN L-A PENICILLIN G BENZATHINE 600,000 UNITS/ML 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0561 60793070010 BICILLIN L-A PENICILLIN G BENZATHINE 600,000 UNITS 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0561 60793070102 BICILLIN L-A PENICILLIN G BENZATHINE 1.2MM/2 ML 2013-06-24 2299-12-31 6 100,000 UNITS ML
J0561 60793070110 BICILLIN L-A PENICILLIN G BENZATHINE 1.2MM/2ML 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0561 60793070110 BICILLIN L-A PENICILLIN G BENZATHINE 1,200,000 UNITS 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0561 60793070204 BICILLIN L-A PENICILLIN G BENZATHINE 2.4MM/4ML 2014-03-13 2299-12-31 6 100,000 UNITS ML
J0561 60793070210 BICILLIN L-A PENICILLIN G BENZATHINE 2.4MM/4ML 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0561 60793070210 BICILLIN L-A PENICILLIN G BENZATHINE 2,400,000 UNITS 2011-01-01 2299-12-31 6 100,000 UNITS ML
J0570 61570014710 BICILLIN L-A PENICILLIN G BENZATHINE 1.2MM/2ML 2007-07-01 2007-11-21 6 100,000 UNITS ML
J0570 60793070110 BICILLIN L-A PENICILLIN G BENZATHINE 1.2MM/2ML 2007-07-01 2010-12-31 6 100,000 UNITS ML
J0580 61570014810 BICILLIN L-A PENICILLIN G BENZATHINE 2.4MM/4ML 2007-07-01 2007-11-21 6 100,000 UNITS ML
J0580 60793070210 BICILLIN L-A PENICILLIN G BENZATHINE 2.4MM/4ML 2007-07-01 2010-12-31 6 100,000 UNITS ML
J0585 00023923250 BOTOX COSMETIC ONABOTULINUMTOXINA 50 UNIT 2008-05-21 2011-01-18 50 1 UNIT EA
J0585 00023114501 BOTOX ONABOTULINUMTOXINA 100 UNIT 2008-01-01 2299-12-31 100 1UNIT EA
J0585 00023391950 BOTOX COSMETIC ONABOTULINUMTOXINA 50 UNIT 2011-07-02 2299-12-31 50 1 UNIT EA
J0585 00023392102 BOTOX ONABOTULINUMTOXINA 200 UNIT 2009-12-31 2299-12-31 200 1 UNIT EA
J0585 00023923201 BOTOX COSMETIC ONABOTULINUMTOXINA 100 UNIT 2008-01-01 2299-12-31 100 1 UNIT EA
J0586 15054050001 DYSPORT ABOBOTULINUMTOXINA 500 UNITS 2009-10-26 2299-12-31 100 5 UNITS EA
J0586 15054053006 DYSPORT ABOBOTULINUMTOXINA 300 UNITS 2010-11-16 2299-12-31 60 5 UNITS EA
J0586 99207050030 DYSPORT ABOBOTULINUMTOXINA 300 UNITS 2013-04-03 2299-12-31 60 5 UNITS EA
J0587 59075071010 MYOBLOC RIMABOTULINUMTOXINB 2500/0.5ML 2008-01-01 2008-09-30 50 100 UNITS ML
J0587 59075071210 MYOBLOC RIMABOTULINUMTOXINB 10000/2ML 2008-01-01 2008-09-30 50 100 UNITS ML
J0587 59075071110 MYOBLOC RIMABOTULINUMTOXINB 5000/ML 2008-01-01 2009-12-15 50 100 UNITS ML
J0587 10454071010 MYOBLOC RIMABOTULINUMTOXINB 2500/0.5ML 2007-07-01 2299-12-31 50 100 UNITS ML
J0587 10454071110 MYOBLOC RIMABOTULINUMTOXINB 5000/ML 2007-07-01 2299-12-31 50 100 UNITS ML
J0587 10454071210 MYOBLOC RIMABOTULINUMTOXINB 10000/2ML 2007-07-01 2299-12-31 50 100 UNITS ML
J0588 00259160501 XEOMIN INCOBOTULINUMTOXINA 50 UNIT 2012-01-01 2299-12-31 50 1 UNIT EA
J0588 00259161001 XEOMIN INCOBOTULINUMTOXINA 100 UNIT 2012-01-01 2299-12-31 100 1 UNIT EA
J0597 63833082502 BERINERT C1 ESTERASE INHIBITOR 500 UNIT 2012-01-01 2299-12-31 50 10 UNITS EA
J0597 63833083501 BERINERT C1 ESTERASE INHIBITOR 500(10 ML) 2012-05-10 2299-12-31 50 10 UNITS EA
J0638 00078058261 ILARIS CANAKINUMAB/PF 180 MG/1.2 2012-01-01 2299-12-31 180 1 MG EA
J0640 49452403601 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 2007-07-01 2009-12-15 20 50 MG EA
J0640 49452403602 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 2007-07-01 2009-12-15 20 50 MG EA
J0640 51927269200 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 2007-07-01 2009-12-15 20 50 MG EA
J0640 55390081810 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 100 MG 2007-07-01 2014-04-18 2 50 MG EA
J0640 55390082401 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 200 MG 2007-07-01 2014-04-18 4 50 MG EA
J0640 55390082501 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 350 MG 2007-07-01 2014-04-18 7 50 MG EA
J0640 55390082601 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 500MG/50ML 2007-07-01 2014-04-18 0.2 50 MG ML
J0640 00703279301 CALCIUM FOLINATE LEUCOVORIN CALCIUM 10 MG/ML 2011-07-08 2014-05-29 0.2 50 MG ML
J0640 55390000901 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 500MG/50ML 2007-07-01 2015-09-05 0.2 50 MG ML
J0640 55390005110 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 50 MG 2007-07-01 2015-09-05 1 50 MG EA
J0640 55390005210 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 100 MG 2007-07-01 2015-09-05 2 50 MG EA
J0640 55390005301 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 200 MG 2007-07-01 2015-09-05 4 50 MG EA
J0640 55390005401 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 350 MG 2007-07-01 2015-09-05 7 50 MG EA
J0640 00703279701 CALCIUM FOLINATE LEUCOVORIN CALCIUM 10 MG/ML 2011-07-08 2299-12-31 0.2 50 MG ML
J0640 00703514001 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 100 MG 2007-07-01 2299-12-31 2 50 MG EA
J0640 00703514501 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 350 MG 2007-07-01 2299-12-31 7 50 MG EA
J0640 00703514591 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 350 MG 2013-05-09 2299-12-31 7 50 MG EA
J0640 25021081310 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 50 MG 2012-10-01 2299-12-31 1 50 MG EA
3
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ0640 25021081366 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 50 MG 2012-11-10 2299-12-31 1 50 MG EA
J0640 25021081430 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 100 MG 2012-10-01 2299-12-31 2 50 MG EA
J0640 25021081467 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 100 MG 2013-09-27 2299-12-31 2 50 MG EA
J0640 25021081530 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 200 MG 2012-10-01 2299-12-31 4 50 MG EA
J0640 25021081567 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 200 MG 2013-09-27 2299-12-31 4 50 MG EA
J0640 25021081630 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 350 MG 2012-10-01 2299-12-31 7 50 MG EA
J0640 25021081667 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 350 MG 2013-08-20 2299-12-31 7 50 MG EA
J0640 63323071050 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 200 MG 2010-11-03 2299-12-31 4 50 MG EA
J0640 63323071059 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 200 MG 2014-09-17 2299-12-31 4 50 MG EA
J0640 63323071100 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 500 MG 2007-07-01 2299-12-31 10 50 MG EA
J0641 00781320194 LEVOLEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM 10 MG/ML 2015-04-23 2299-12-31 20 0.5 MG ML
J0641 68152010100 FUSILEV LEVOLEUCOVORIN CALCIUM 50 MG 2009-01-01 2299-12-31 100 0.5 MG EA
J0712 00456040001 TEFLARO CEFTAROLINE FOSAMIL ACETATE 400 MG 2012-01-01 2299-12-31 40 10 MG EA
J0712 00456040010 TEFLARO CEFTAROLINE FOSAMIL ACETATE 400 MG 2012-01-01 2299-12-31 40 10 MG EA
J0712 00456060001 TEFLARO CEFTAROLINE FOSAMIL ACETATE 600 MG 2012-01-01 2299-12-31 60 10 MG EA
J0712 00456060010 TEFLARO CEFTAROLINE FOSAMIL ACETATE 600 MG 2012-01-01 2299-12-31 60 10 MG EA
J0716 66621015001 ANASCORP CENTRUROIDES (SCORPN) ANTIVENOM 120 MG 2013-01-01 2299-12-31 1 120 MG EA
J0775 66887000301 XIAFLEX COLLAGENASE CLOSTRIDIUM HIST. 0.9 MG 2012-01-01 2299-12-31 90 0.01 MG EA
J0850 44206310110 CYTOGAM CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML 2007-07-01 2010-05-27 1 1 EA ML
J0850 44206310101 CYTOGAM CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML 2007-07-01 2012-06-14 1 1 EA ML
J0850 44206053211 CYTOGAM CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML 2011-01-18 2299-12-31 1 1 EA ML
J0881 55513004101 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 100MCG/0.5 2007-07-01 2007-08-31 200 1 MCG ML
J0881 55513004104 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 100MCG/0.5 2007-07-01 2007-08-31 200 1 MCG ML
J0881 55513004401 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 200MCG/0.4 2007-07-01 2007-08-31 500 1 MCG ML
J0881 55513005801 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 25MCG/0.42 2007-07-01 2007-09-05 59.52381 1 MCG ML
J0881 55513005804 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 25MCG/0.42 2007-07-01 2007-09-05 59.52381 1 MCG ML
J0881 55513001501 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 300MCG/ML 2007-07-01 2007-09-06 300 1 MCG ML
J0881 55513003701 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 40MCG/0.4 2007-07-01 2007-09-06 100 1 MCG ML
J0881 55513003704 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 40MCG/0.4 2007-07-01 2007-09-06 100 1 MCG ML
J0881 55513004601 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 300MCG/0.6 2007-07-01 2007-09-06 500 1 MCG ML
J0881 55513001301 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 100 MCG/ML 2007-07-01 2007-10-06 100 1 MCG ML
J0881 55513001304 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 100 MCG/ML 2007-07-01 2007-10-06 100 1 MCG ML
J0881 55513001001 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 25 MCG/ML 2007-07-01 2007-10-10 25 1 MCG ML
J0881 55513001004 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 25 MCG/ML 2007-07-01 2007-10-10 25 1 MCG ML
J0881 55513001101 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 40MCG/ML 2007-07-01 2007-10-10 40 1 MCG ML
J0881 55513001104 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 40MCG/ML 2007-07-01 2007-10-10 40 1 MCG ML
J0881 55513001201 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 60MCG/ML 2007-07-01 2007-10-10 60 1 MCG ML
J0881 55513001204 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 60MCG/ML 2007-07-01 2007-10-10 60 1 MCG ML
J0881 55513003901 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 60MCG/0.3 2007-07-01 2007-10-10 200 1 MCG ML
J0881 55513003904 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 60MCG/0.3 2007-07-01 2007-10-10 200 1 MCG ML
J0881 55513005401 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 150MCG/.75 2007-07-01 2007-10-31 200 1 MCG ML
J0881 55513005404 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 150MCG/.75 2007-07-01 2007-10-31 200 1 MCG ML
J0881 55513001401 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 200 MCG/ML 2007-07-01 2007-11-01 200 1 MCG ML
J0881 55513004301 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 150MCG/0.3 2007-07-01 2007-12-26 500 1 MCG ML
J0881 55513004304 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 150MCG/0.3 2007-07-01 2007-12-26 500 1 MCG ML
J0881 55513001404 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 200 MCG/ML 2007-07-01 2009-12-15 200 1 MCG ML
J0881 55513004801 ARANESP DARBEPOETIN ALFA IN ALBUMN SOL 500MCG/ML 2007-07-01 2009-12-15 500 1 MCG ML
J0881 55513009001 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 25MCG/0.42 2007-07-01 2010-02-28 59.52381 1 MCG ML
J0881 55513009101 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 40MCG/0.4 2007-07-01 2010-02-28 100 1 MCG ML
J0881 55513009201 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 60MCG/0.3 2007-07-01 2010-02-28 200 1 MCG ML
J0881 55513009301 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 100MCG/0.5 2007-07-01 2010-02-28 200 1 MCG ML
J0881 55513009401 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 150MCG/0.3 2007-07-01 2010-02-28 500 1 MCG ML
J0881 55513009501 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 200MCG/0.4 2007-07-01 2010-02-28 500 1 MCG ML
J0881 55513009601 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 300MCG/0.6 2007-07-01 2010-02-28 500 1 MCG ML
J0881 55513009701 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 500MCG/ML 2007-07-01 2010-02-28 500 1 MCG ML
J0881 55513005304 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 150MCG/.75 2007-07-01 2015-12-02 200 1 MCG ML
J0881 55513000201 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/ML 2007-07-01 2299-12-31 25 1 MCG ML
J0881 55513000204 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/ML 2007-07-01 2299-12-31 25 1 MCG ML
J0881 55513000301 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 40MCG/ML 2007-07-01 2299-12-31 40 1 MCG ML
4
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ0881 55513000304 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 40MCG/ML 2007-07-01 2299-12-31 40 1 MCG ML
J0881 55513000401 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 60MCG/ML 2007-07-01 2299-12-31 60 1 MCG ML
J0881 55513000404 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 60MCG/ML 2007-07-01 2299-12-31 60 1 MCG ML
J0881 55513000501 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/ML 2007-07-01 2299-12-31 100 1 MCG ML
J0881 55513000504 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/ML 2007-07-01 2299-12-31 100 1 MCG ML
J0881 55513000601 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/ML 2007-07-01 2299-12-31 200 1 MCG ML
J0881 55513002101 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 40MCG/0.4 2007-07-01 2299-12-31 40 1 MCG ML
J0881 55513002104 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 40MCG/0.4 2007-07-01 2299-12-31 40 1 MCG ML
J0881 55513002301 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 60MCG/0.3 2007-07-01 2299-12-31 60 1 MCG ML
J0881 55513002304 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 60MCG/0.3 2007-07-01 2299-12-31 60 1 MCG ML
J0881 55513002501 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 100MCG/0.5 2007-07-01 2299-12-31 100 1 MCG ML
J0881 55513002504 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 100MCG/0.5 2007-07-01 2299-12-31 100 1 MCG ML
J0881 55513002701 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 150MCG/0.3 2007-07-01 2299-12-31 500 1 MCG ML
J0881 55513002704 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 150MCG/0.3 2007-07-01 2299-12-31 500 1 MCG ML
J0881 55513002801 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 200MCG/0.4 2007-07-01 2299-12-31 500 1 MCG ML
J0881 55513003201 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 500MCG/ML 2007-07-01 2299-12-31 500 1 MCG ML
J0881 55513005301 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 150MCG/.75 2007-07-01 2299-12-31 200 1 MCG ML
J0881 55513005701 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 25MCG/0.42 2007-07-01 2299-12-31 59.52381 1 MCG ML
J0881 55513005704 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 25MCG/0.42 2007-07-01 2299-12-31 59.52381 1 MCG ML
J0881 55513009801 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 10MCG/0.4 2015-03-16 2299-12-31 25 1 MCG ML
J0881 55513009804 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 10MCG/0.4 2015-03-16 2299-12-31 25 1 MCG ML
J0881 55513011001 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 300MCG/ML 2007-07-01 2299-12-31 300 1 MCG ML
J0881 55513011101 ARANESP DARBEPOETIN ALFA IN POLYSORBAT 300MCG/0.6 2007-07-01 2299-12-31 500 1 MCG ML
J0885 59676031200 PROCRIT EPOETIN ALFA 20000/2ML 2007-07-01 2007-05-19 10 1000 UNITS ML
J0885 54868252300 PROCRIT EPOETIN ALFA 10000/ML 2007-07-01 2009-12-15 10 1000 UNITS ML
J0885 54868252301 PROCRIT EPOETIN ALFA 10000/ML 2007-07-01 2009-12-15 10 1000 UNITS ML
J0885 55513082301 EPOGEN EPOETIN ALFA 40000/ML 2007-07-01 2011-07-31 40 1000 UNITS ML
J0885 55513082310 EPOGEN EPOETIN ALFA 40000/ML 2007-07-01 2011-07-31 40 1000 UNITS ML
J0885 59676031201 PROCRIT EPOETIN ALFA 20000/2ML 2007-07-01 2011-11-09 10 1000 UNITS ML
J0885 59676032001 PROCRIT EPOETIN ALFA 20000/ML 2007-07-01 2011-11-09 20 1000 UNITS ML
J0885 59676030202 PROCRIT EPOETIN ALFA 2000/ML 2007-07-01 2014-06-30 2 1000 UNITS ML
J0885 59676030302 PROCRIT EPOETIN ALFA 3000/ML 2007-07-01 2014-08-31 3 1000 UNITS ML
J0885 59676030402 PROCRIT EPOETIN ALFA 4000/ML 2007-07-01 2014-08-31 4 1000 UNITS ML
J0885 55513012601 EPOGEN EPOETIN ALFA 2000/ML 2007-07-01 2299-12-31 2 1000 UNITS ML
J0885 55513012610 EPOGEN EPOETIN ALFA 2000/ML 2007-07-01 2299-12-31 2 1000 UNITS ML
J0885 55513014401 EPOGEN EPOETIN ALFA 10000/ML 2007-07-01 2299-12-31 10 1000 UNITS ML
J0885 55513014410 EPOGEN EPOETIN ALFA 10000/ML 2007-07-01 2299-12-31 10 1000 UNITS ML
J0885 55513014801 EPOGEN EPOETIN ALFA 4000/ML 2007-07-01 2299-12-31 4 1000 UNITS ML
J0885 55513014810 EPOGEN EPOETIN ALFA 4000/ML 2007-07-01 2299-12-31 4 1000 UNITS ML
J0885 55513026701 EPOGEN EPOETIN ALFA 3000/ML 2007-07-01 2299-12-31 3 1000 UNITS ML
J0885 55513026710 EPOGEN EPOETIN ALFA 3000/ML 2007-07-01 2299-12-31 3 1000 UNITS ML
J0885 55513028301 EPOGEN EPOETIN ALFA 20000/2ML 2007-07-01 2299-12-31 10 1000 UNITS ML
J0885 55513028310 EPOGEN EPOETIN ALFA 20000/2ML 2007-07-01 2299-12-31 10 1000 UNITS ML
J0885 55513047801 EPOGEN EPOETIN ALFA 20000/ML 2007-07-01 2299-12-31 20 1000 UNITS ML
J0885 55513047810 EPOGEN EPOETIN ALFA 20000/ML 2007-07-01 2299-12-31 20 1000 UNITS ML
J0885 59676030201 PROCRIT EPOETIN ALFA 2000/ML 2007-07-01 2299-12-31 2 1000 UNITS ML
J0885 59676030300 PROCRIT EPOETIN ALFA 3000/ML 2015-08-03 2299-12-31 3 1000 UNITS ML
J0885 59676030301 PROCRIT EPOETIN ALFA 3000/ML 2007-07-01 2299-12-31 3 1000 UNITS ML
J0885 59676030400 PROCRIT EPOETIN ALFA 4000/ML 2015-08-03 2299-12-31 4 1000 UNITS ML
J0885 59676030401 PROCRIT EPOETIN ALFA 4000/ML 2007-07-01 2299-12-31 4 1000 UNITS ML
J0885 59676031000 PROCRIT EPOETIN ALFA 10000/ML 2007-07-01 2299-12-31 10 1000 UNITS ML
J0885 59676031001 PROCRIT EPOETIN ALFA 10000/ML 2007-07-01 2299-12-31 10 1000 UNITS ML
J0885 59676031002 PROCRIT EPOETIN ALFA 10000/ML 2007-07-01 2299-12-31 10 1000 UNITS ML
J0885 59676031204 PROCRIT EPOETIN ALFA 20000/2ML 2008-01-18 2299-12-31 10 1000 UNITS ML
J0885 59676032000 PROCRIT EPOETIN ALFA 20000/ML 2013-09-06 2299-12-31 2 1000 UNITS ML
J0885 59676032004 PROCRIT EPOETIN ALFA 20000/ML 2007-10-15 2299-12-31 20 1000 UNITS ML
J0885 59676034000 PROCRIT EPOETIN ALFA 40000/ML 2015-05-27 2299-12-31 4 1000 UNITS ML
J0885 59676034001 PROCRIT EPOETIN ALFA 40000/ML 2007-07-01 2299-12-31 40 1000 UNITS ML
J0888 00004040109 MIRCERA METHOXY PEG-EPOETIN BETA 50 MCG/0.3 ML 2015-01-01 2299-12-31 150 1 MCG ML
5
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ0888 00004040209 MIRCERA METHOXY PEG-EPOETIN BETA 75 MCG/0.3 ML 2015-01-01 2299-12-31 225 1 MCG ML
J0888 00004040309 MIRCERA METHOXY PEG-EPOETIN BETA 100 MCG/0.3 ML 2015-01-01 2299-12-31 330 1 MCG ML
J0888 00004040509 MIRCERA METHOXY PEG-EPOETIN BETA 200MCG/0.3 2015-03-04 2299-12-31 666 1 MCG ML
J0890 64764061010 OMONTYS PEGINESATIDE 10MG/ML 2013-01-01 2014-02-25 100 0.1 MG ML
J0890 64764062020 OMONTYS PEGINESATIDE 20MG/2ML 2013-01-01 2014-02-25 100 0.1 MG ML
J0897 55513071001 PROLIA DENOSUMAB 60 MG/ML 2012-01-01 2299-12-31 60 1 MG ML
J0897 55513073001 XGEVA DENOSUMAB 120 MG/1.7 2012-01-01 2299-12-31 70 1 MG ML
J1050 00009074630 DEPO-PROVERA MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 00009074635 DEPO-PROVERA MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 00009737611 DEPO-PROVERA MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 00703680101 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 00703680104 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 59762453701 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 59762453702 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 59762453801 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1050 59762453802 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 150 MG/ML 2013-01-01 2299-12-31 150 1 MG ML
J1071 00009008510 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 100 MG/ML 2015-01-01 2299-12-31 100 1 MG ML
J1071 00009008601 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00009008610 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00009034702 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 100 MG/ML 2015-01-01 2299-12-31 100 1 MG ML
J1071 00009041701 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00009041702 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00009052001 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00009052010 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00143972601 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00574082001 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00574082010 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00574082710 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00591412879 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-03-05 2299-12-31 200 1 MG ML
J1071 00781307370 TESTOSTERON CYP TESTOSTERONE CYPIONATE 100 MG/ML 2015-01-01 2299-12-31 100 1 MG ML
J1071 00781307470 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 00781307471 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 62756001540 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 62756001640 TESTOSTERON CYP TESTOSTERONE CYPIONATE 200 MG/ML 2015-01-01 2299-12-31 200 1 MG ML
J1071 62756001740 TESTOSTERON CYP TESTOSTERONE CYPIONATE 100 MG/ML 2015-01-01 2299-12-31 100 1 MG ML
J1170 00044101101 DILAUDID HYDROMORPHONE HCL/PF 1 MG/ML 2007-07-01 2009-12-15 0.25 4 MG ML
J1170 00044101201 DILAUDID HYDROMORPHONE HCL/PF 2 MG/ML 2007-07-01 2009-12-15 0.5 4 MG ML
J1170 00044101209 DILAUDID HYDROMORPHONE HCL/PF 2 MG/ML 2007-07-01 2009-12-15 0.5 4 MG ML
J1170 00044101401 DILAUDID HYDROMORPHONE HCL/PF 4 MG/ML 2007-07-01 2009-12-15 1 4 MG ML
J1170 00044101706 DILAUDID-HP HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2009-12-15 2.5 4 MG ML
J1170 00044101710 DILAUDID-HP HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2009-12-15 2.5 4 MG ML
J1170 00044101725 DILAUDID-HP HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2009-12-15 2.5 4 MG ML
J1170 00044104001 DILAUDID HYDROMORPHONE HCL 100 % 2007-07-01 2009-12-15 250 4 MG ML
J1170 00044106205 DILAUDID HYDROMORPHONE HCL 2 MG/ML 2007-07-01 2009-12-15 0.5 4 MG ML
J1170 00044191101 DILAUDID-HP HYDROMORPHONE HCL/PF 250 MG 2007-07-01 2009-12-15 62.5 4 MG ML
J1170 00074128301 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 1 MG/ML 2007-07-01 2009-12-15 0.25 4 MG ML
J1170 00555111705 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2012-01-06 2.5 4 MG ML
J1170 00555111706 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2012-01-06 2.5 4 MG ML
J1170 00555111707 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2012-01-06 2.5 4 MG ML
J1170 00703011301 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2012-12-19 2013-04-29 2.5 4 MG ML
J1170 00409217201 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2014-06-27 2.5 4 MG ML
J1170 00409217205 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2014-06-27 2.5 4 MG ML
J1170 59011044110 DILAUDID HYDROMORPHONE HCL/PF 1 MG/ML 2009-01-01 2016-05-08 0.25 4 MG ML
J1170 59011044550 DILAUDID-HP HYDROMORPHONE HCL/PF 10 MG/ML 2008-11-03 2016-07-27 2.5 4 MG ML
J1170 59011044625 DILAUDID-HP HYDROMORPHONE HCL/PF 250 MG 2008-11-03 2016-07-27 62.5 4 MG ML
J1170 00409128305 HYDROMORPHONE HCL HYDROMORPHONE HCL 0.5MG/.5ML 2013-08-16 2299-12-31 0.25 4 MG ML
J1170 00409128310 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 1 MG/ML 2011-02-08 2299-12-31 0.25 4 MG ML
J1170 00409128331 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 1 MG/ML 2007-07-01 2299-12-31 0.25 4 MG ML
J1170 00409130431 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 4 MG/ML 2007-07-01 2299-12-31 1 4 MG ML
6
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ1170 00409131210 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 2 MG/ML 2011-02-08 2299-12-31 0.5 4 MG ML
J1170 00409131230 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 2 MG/ML 2007-07-01 2299-12-31 0.5 4 MG ML
J1170 00409254001 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 4 MG/ML 2007-07-01 2299-12-31 1 4 MG ML
J1170 00409255201 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 1 MG/ML 2007-07-01 2299-12-31 0.25 4 MG ML
J1170 00409263401 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2008-07-18 2299-12-31 2.5 4 MG ML
J1170 00409263405 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2008-07-18 2299-12-31 2.5 4 MG ML
J1170 00409263450 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2008-07-18 2299-12-31 2.5 4 MG ML
J1170 00409335601 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 2 MG/ML 2007-07-01 2299-12-31 0.5 4 MG ML
J1170 00409336501 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 2 MG/ML 2007-07-01 2299-12-31 0.5 4 MG ML
J1170 00641012121 HYDROMORPHONE HCL HYDROMORPHONE HCL 2 MG/ML 2007-07-01 2299-12-31 0.5 4 MG ML
J1170 00641012125 HYDROMORPHONE HCL HYDROMORPHONE HCL 2 MG/ML 2007-07-01 2299-12-31 0.5 4 MG ML
J1170 00641234139 HYDROMORPHONE HCL HYDROMORPHONE HCL 2 MG/ML 2007-07-01 2299-12-31 0.5 4 MG ML
J1170 00641234141 HYDROMORPHONE HCL HYDROMORPHONE HCL 2 MG/ML 2007-07-01 2299-12-31 0.5 4 MG ML
J1170 00703001801 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2011-01-06 2299-12-31 2.5 4 MG ML
J1170 00703011003 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2011-01-06 2299-12-31 2.5 4 MG ML
J1170 00703011303 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2011-01-06 2299-12-31 2.5 4 MG ML
J1170 17478054001 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2299-12-31 2.5 4 MG ML
J1170 17478054005 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2299-12-31 2.5 4 MG ML
J1170 17478054050 HYDROMORPHONE HCL HYDROMORPHONE HCL/PF 10 MG/ML 2007-07-01 2299-12-31 2.5 4 MG ML
J1170 59011044210 DILAUDID HYDROMORPHONE HCL/PF 2 MG/ML 2008-11-03 2299-12-31 0.5 4 MG ML
J1170 59011044225 DILAUDID HYDROMORPHONE HCL/PF 2 MG/ML 2009-01-01 2299-12-31 0.5 4 MG ML
J1170 59011044410 DILAUDID HYDROMORPHONE HCL/PF 4 MG/ML 2008-11-03 2299-12-31 1 4 MG ML
J1170 59011044501 DILAUDID-HP HYDROMORPHONE HCL/PF 10 MG/ML 2008-11-03 2299-12-31 2.5 4 MG ML
J1170 59011044505 DILAUDID-HP HYDROMORPHONE HCL/PF 10 MG/ML 2008-11-03 2299-12-31 2.5 4 MG ML
J1190 00013871562 ZINECARD DEXRAZOXANE 250 MG 2007-07-01 2010-01-01 1 250 MG EA
J1190 00013872589 ZINECARD DEXRAZOXANE 500 MG 2007-07-01 2010-01-01 2 250 MG EA
J1190 55390001402 DEXRAZOXANE DEXRAZOXANE 250 MG 2007-07-01 2015-09-05 1 250 MG EA
J1190 55390006002 DEXRAZOXANE DEXRAZOXANE 500 MG 2007-07-01 2015-09-05 2 250 MG EA
J1190 00013871762 ZINECARD DEXRAZOXANE 250 MG 2009-09-10 2299-12-31 1 250 MG EA
J1190 00013872789 ZINECARD DEXRAZOXANE 500 MG 2009-09-10 2299-12-31 2 250 MG EA
J1190 67457020425 DEXRAZOXANE DEXRAZOXANE 250 MG 2009-10-10 2299-12-31 1 250 MG EA
J1190 67457020725 DEXRAZOXANE DEXRAZOXANE 250 MG 2009-10-10 2299-12-31 1 250 MG EA
J1190 67457020850 DEXRAZOXANE DEXRAZOXANE 500 MG 2009-10-10 2299-12-31 1 250 MG EA
J1190 67457020950 DEXRAZOXANE DEXRAZOXANE 500 MG 2009-10-10 2299-12-31 1 250 MG EA
J1200 00409229031 DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG/ML 2014-11-25 2299-12-31 1 50 MG ML
J1200 00641037621 DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG/ML 2014-11-25 2299-12-31 1 50 MG ML
J1200 00641037625 DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG/ML 2014-11-25 2299-12-31 1 50 MG ML
J1200 63323066401 DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG/ML 2014-11-25 2299-12-31 1 50 MG ML
J1200 67457012410 DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG/ML 2014-11-25 2299-12-31 1 50 MG ML
J1200 76045010210 DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG/ML 2014-11-25 2299-12-31 1 50 MG ML
J1260 00088120876 ANZEMET DOLASETRON MESYLATE 12.5/0.625 2007-07-01 2011-01-04 2 10 MG ML
J1260 00088120632 ANZEMET DOLASETRON MESYLATE 100 MG/5ML 2007-07-01 2299-12-31 2 10 MG ML
J1260 00088120806 ANZEMET DOLASETRON MESYLATE 12.5/0.625 2007-07-01 2299-12-31 2 10 MG ML
J1260 00088120926 ANZEMET DOLASETRON MESYLATE 20 MG/ML 2007-07-01 2299-12-31 2 10 MG ML
J1290 47783010101 KALBITOR ECALLANTIDE 10MG/ML(1) 2012-01-01 2299-12-31 10 1 MG ML
J1322 68135010001 VIMIZIM ELOSULFASE ALFA 5 MG/ML 2015-01-01 2299-12-31 5 1 MG ML
J1439 00517065001 INJECTAFER FERRIC CARBOXYMALTOSE 750 MG/15 ML 2015-01-01 2299-12-31 50 1 MG ML
J1440 54868252200 NEUPOGEN FILGRASTIM 300MCG/ML 2007-07-01 2009-12-15 1 300 MCG ML
J1440 54868502000 NEUPOGEN FILGRASTIM 300MCG/0.5 2007-07-01 2013-06-30 2 300 MCG ML
J1440 55513053001 NEUPOGEN FILGRASTIM 300MCG/ML 2007-07-01 2013-12-31 1 300 MCG ML
J1440 55513053010 NEUPOGEN FILGRASTIM 300MCG/ML 2007-07-01 2013-12-31 1 300 MCG ML
J1440 55513092401 NEUPOGEN FILGRASTIM 300MCG/0.5 2007-07-01 2013-12-31 2 300 MCG ML
J1440 55513092410 NEUPOGEN FILGRASTIM 300MCG/0.5 2007-07-01 2013-12-31 2 300 MCG ML
J1441 54868305000 NEUPOGEN FILGRASTIM 480MCG/0.8 2007-07-01 2009-12-15 1.25 480 MCG ML
J1441 55513020901 NEUPOGEN FILGRASTIM 480MCG/0.8 2007-07-01 2013-12-31 1.25 480 MCG ML
J1441 55513020910 NEUPOGEN FILGRASTIM 480MCG/0.8 2007-07-01 2013-12-31 1.25 480 MCG ML
J1441 55513054601 NEUPOGEN FILGRASTIM 480MCG/1.6 2007-07-01 2013-12-31 0.625 480 MCG ML
J1441 55513054610 NEUPOGEN FILGRASTIM 480MCG/1.6 2007-07-01 2013-12-31 0.625 480 MCG ML
J1442 55513020901 NEUPOGEN FILGRASTIM 480MCG/0.8 2014-01-01 2299-12-31 600 1 MCG ML
7
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ1442 55513020910 NEUPOGEN FILGRASTIM 480MCG/0.8 2014-01-01 2299-12-31 600 1 MCG ML
J1442 55513020991 NEUPOGEN FILGRASTIM 480MCG/0.8 2014-04-07 2299-12-31 600 1 MCG ML
J1442 55513053001 NEUPOGEN FILGRASTIM 300MCG/ML 2014-01-01 2299-12-31 300 1 MCG ML
J1442 55513053010 NEUPOGEN FILGRASTIM 300MCG/ML 2014-01-01 2299-12-31 300 1 MCG ML
J1442 55513054601 NEUPOGEN FILGRASTIM 480MCG/1.6 2014-01-01 2299-12-31 300 1 MCG ML
J1442 55513054610 NEUPOGEN FILGRASTIM 480MCG/1.6 2014-01-01 2299-12-31 300 1 MCG ML
J1442 55513092401 NEUPOGEN FILGRASTIM 300MCG/0.5 2014-01-01 2299-12-31 600 1 MCG ML
J1442 55513092410 NEUPOGEN FILGRASTIM 300MCG/0.5 2014-01-01 2299-12-31 600 1 MCG ML
J1442 55513092491 NEUPOGEN FILGRASTIM 300MCG/0.5 2014-04-07 2299-12-31 600 1 MCG ML
J1446 63459091011 GRANIX TBO-FILGRASTIM 300 MGC/0.5 ML 2014-01-01 2015-12-31 120 5 MCG ML
J1446 63459091012 GRANIX TBO-FILGRASTIM 300MCG/0.5 2015-04-02 2299-12-31 120 5 MCG ML
J1446 63459091015 GRANIX TBO-FILGRASTIM 300 MGC/0.5 ML 2014-01-01 2015-12-31 120 5 MCG ML
J1446 63459091017 GRANIX TBO-FILGRASTIM 300MCG/0.5 2015-02-03 2015-12-31 120 5 MCG ML
J1446 63459091036 GRANIX TBO-FILGRASTIM 300MCG/0.5 2015-02-03 2015-12-31 120 5 MCG ML
J1446 63459091211 GRANIX TBO-FILGRASTIM 480 MGC/0.8 ML 2014-01-01 2015-12-31 120 5 MCG ML
J1446 63459091212 GRANIX TBO-FILGRASTIM 480MCG/0.8 2015-04-02 2299-12-31 120 5 MCG ML
J1446 63459091215 GRANIX TBO-FILGRASTIM 480 MGC/0.8 ML 2014-01-01 2015-12-31 120 5 MCG ML
J1446 63459091217 GRANIX TBO-FILGRASTIM 480MCG/0.8 2015-02-03 2015-12-31 120 5 MCG ML
J1446 63459091236 GRANIX TBO-FILGRASTIM 480MCG/0.8 2015-02-03 2015-12-31 120 5 MCG ML
J1447 63459091011 GRANIX TBO-FILGRASTIM 300 MGC/0.5 ML 2016-01-01 2299-12-31 0.5 1 MCG ML
J1447 63459091015 GRANIX TBO-FILGRASTIM 300 MGC/0.5 ML 2016-01-01 2299-12-31 0.5 1 MCG ML
J1447 63459091017 GRANIX TBO-FILGRASTIM 300MCG/0.5 2016-01-01 2299-12-31 0.5 1 MCG ML
J1447 63459091036 GRANIX TBO-FILGRASTIM 300MCG/0.5 2016-01-01 2299-12-31 0.5 1 MCG ML
J1447 63459091211 GRANIX TBO-FILGRASTIM 480 MGC/0.8 ML 2016-01-01 2299-12-31 0.8 1 MCG ML
J1447 63459091215 GRANIX TBO-FILGRASTIM 480 MGC/0.8 ML 2016-01-01 2299-12-31 0.8 1 MCG ML
J1447 63459091217 GRANIX TBO-FILGRASTIM 480MCG/0.8 2016-01-01 2299-12-31 0.8 1 MCG ML
J1447 63459091236 GRANIX TBO-FILGRASTIM 480MCG/0.8 2016-01-01 2299-12-31 0.8 1 MCG ML
J1453 00006394101 EMEND FOSAPREPITANT DIMEGLUMINE 150 MG 2012-07-24 2012-12-27 150 1 MG EA
J1453 00006388432 EMEND FOSAPREPITANT DIMEGLUMINE 115MG 2008-01-30 2013-07-31 115 1 MG EA
J1453 00006394132 EMEND FOSAPREPITANT DIMEGLUMINE 150 MG 2011-02-08 2299-12-31 150 1 MG EA
J1458 68135002001 NAGLAZYME GALSULFASE 5 MG/5 ML 2007-07-01 2299-12-31 1 1 MG ML
J1459 59730650201 BIVIGAM IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2012-12-19 2013-12-31 0.2 500 MG ML
J1459 59730650301 BIVIGAM IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2012-12-19 2013-12-31 0.2 500 MG ML
J1459 44206043605 PRIVIGEN IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2009-01-01 2299-12-31 0.2 500 MG ML
J1459 44206043710 PRIVIGEN IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2009-01-01 2299-12-31 0.2 500 MG ML
J1459 44206043820 PRIVIGEN IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2009-01-01 2299-12-31 0.2 500 MG ML
J1459 44206043940 PRIVIGEN IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2013-05-20 2299-12-31 0.2 500 MG ML
J1460 54569527500 BAYGAM IMMUNE GLOBULIN,GAMMA (IGG) 15%-18% 2007-07-01 2007-09-26 1 1 ML ML
J1460 54868419300 BAYGAM IMMUNE GLOBULIN,GAMMA (IGG) 15%-18% 2007-07-01 2007-10-03 1 1 ML ML
J1460 13533063503 GAMASTAN S-D IMMUNE GLOBULIN,GAMMA (IGG) 15%-18% 2008-01-17 2012-06-01 1 1 ML ML
J1460 13533063504 GAMASTAN S-D IMMUNE GLOBULIN,GAMMA (IGG) 15%-18% 2007-07-01 2299-12-31 1 1 ML ML
J1460 13533063512 GAMASTAN S-D IMMUNE GLOBULIN,GAMMA (IGG) 15%-18% 2007-07-01 2299-12-31 1 1 ML ML
J1556 59730650201 BIVIGAM IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2014-01-01 2299-12-31 0.2 500 MG ML
J1556 59730650301 BIVIGAM IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2014-01-01 2299-12-31 0.2 500 MG ML
J1557 64208823401 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2012-05-26 2016-01-31 0.1 500 MG ML
J1557 64208823405 GAMMAPLEX IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-07-26 2016-01-31 0.1 500 MG ML
J1557 64208823402 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2012-05-26 2299-12-31 0.1 500 MG ML
J1557 64208823403 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2012-05-26 2299-12-31 0.1 500 MG ML
J1557 64208823404 GAMMAPLEX IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2014-06-16 2299-12-31 0.1 500 MG ML
J1557 64208823406 GAMMAPLEX IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-07-26 2299-12-31 0.1 500 MG ML
J1557 64208823407 GAMMAPLEX IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-07-26 2299-12-31 0.1 500 MG ML
J1557 64208823408 GAMMAPLEX IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2014-06-16 2299-12-31 0.1 500 MG ML
J1561 13533064512 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2008-01-01 2014-03-24 0.2 500 MG ML
J1561 13533064515 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2008-01-01 2014-04-19 0.2 500 MG ML
J1561 13533064524 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2008-01-01 2014-10-17 0.2 500 MG ML
J1561 13533064571 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2008-01-01 2014-10-22 0.2 500 MG ML
J1561 13533064520 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2008-01-01 2015-06-26 0.2 500 MG ML
J1561 13533080012 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 1G/10ML 2011-02-08 2299-12-31 0.2 500 MG ML
J1561 13533080013 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 1 G/10 ML 2013-12-23 2299-12-31 0.2 500 MG ML
8
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ1561 13533080015 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 2.5G/25ML 2011-02-08 2299-12-31 0.2 500 MG ML
J1561 13533080016 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 2.5G/25ML 2013-12-23 2299-12-31 0.2 500 MG ML
J1561 13533080020 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 5G/50ML 2011-02-08 2299-12-31 0.2 500 MG ML
J1561 13533080021 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 5 G/50 ML 2013-12-23 2299-12-31 0.2 500 MG ML
J1561 13533080024 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 20G/200ML 2011-02-08 2299-12-31 0.2 500 MG ML
J1561 13533080025 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 20 G/200ML 2013-05-16 2299-12-31 0.2 500 MG ML
J1561 13533080040 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 40 G/400ML 2014-10-01 2299-12-31 0.2 500 MG ML
J1561 13533080041 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 40 G/400ML 2014-10-29 2299-12-31 0.2 500 MG ML
J1561 13533080071 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 10G/100ML 2011-02-08 2299-12-31 0.2 500 MG ML
J1561 13533080072 GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 G/100ML 2013-05-16 2299-12-31 0.2 500 MG ML
J1561 76125090001 GAMMAKED IMMUNE GLOB,GAM CAPRYLATE(IGG) 1G/10ML 2011-12-05 2299-12-31 0.2 500 MG ML
J1561 76125090010 GAMMAKED IMMUNE GLOB,GAM CAPRYLATE(IGG) 10G/100ML 2011-12-05 2299-12-31 0.2 500 MG ML
J1561 76125090020 GAMMAKED IMMUNE GLOB,GAM CAPRYLATE(IGG) 20G/200ML 2011-12-05 2299-12-31 0.2 500 MG ML
J1561 76125090025 GAMMAKED IMMUNE GLOB,GAM CAPRYLATE(IGG) 2.5G/25ML 2011-12-05 2299-12-31 0.2 500 MG ML
J1561 76125090050 GAMMAKED IMMUNE GLOB,GAM CAPRYLATE(IGG) 5G/50ML 2011-12-05 2299-12-31 0.2 500 MG ML
J1566 00053748605 GAMMAR-P I.V. IMMUNE GLOBULIN,GAMMA (IGG) 5G 2007-07-01 2007-11-17 10 500 MG EA
J1566 00053748610 GAMMAR-P I.V. IMMUNE GLOBULIN,GAMMA (IGG) 10 G 2007-07-01 2007-11-17 20 500 MG EA
J1566 44206041501 CARIMUNE NF NANOFILTERED IMMUNE GLOBULIN,GAMMA (IGG) 1 G 2007-07-01 2008-02-08 2 500 MG EA
J1566 52769041706 PANGLOBULIN NF IMMUNE GLOBULIN,GAMMA (IGG) 6G 2007-07-01 2008-05-15 12 500 MG EA
J1566 52769041812 PANGLOBULIN NF IMMUNE GLOBULIN,GAMMA (IGG) 12G 2007-07-01 2008-05-15 24 500 MG EA
J1566 00944047169 POLYGAM S-D IMMUNE GLOBULIN,GAMMA (IGG) 0.5G 2007-07-01 2009-12-15 1 500 MG EA
J1566 00944047172 POLYGAM S-D IMMUNE GLOBULIN,GAMMA (IGG) 2.5 G 2007-07-01 2009-12-15 5 500 MG EA
J1566 00944047175 POLYGAM S-D IMMUNE GLOBULIN,GAMMA (IGG) 5G 2007-07-01 2009-12-15 10 500 MG EA
J1566 00944047180 POLYGAM S-D IMMUNE GLOBULIN,GAMMA (IGG) 10 G 2007-07-01 2009-12-15 20 500 MG EA
J1566 52769047072 POLYGAM IMMUNE GLOBULIN,GAMMA (IGG) 2.5 G 2007-07-01 2009-12-15 5 500 MG EA
J1566 64193025050 IVEEGAM EN IMMUNE GLOBULIN,GAMMA (IGG) 5G 2007-07-01 2009-12-15 10 500 MG EA
J1566 00944262001 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA (IGG) 0.5G 2007-07-01 2011-12-03 1 500 MG EA
J1566 44206041603 CARIMUNE NF NANOFILTERED IMMUNE GLOBULIN,GAMMA (IGG) 3 G 2007-07-01 2011-12-31 6 500 MG EA
J1566 44206041706 CARIMUNE NF NANOFILTERED IMMUNE GLOBULIN,GAMMA (IGG) 6G 2007-07-01 2011-12-31 12 500 MG EA
J1566 44206041812 CARIMUNE NF NANOFILTERED IMMUNE GLOBULIN,GAMMA (IGG) 12G 2007-07-01 2011-12-31 24 500 MG EA
J1566 00944262002 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA (IGG) 2.5 G 2007-07-01 2014-05-25 5 500 MG EA
J1566 00944262003 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA (IGG) 5G 2007-07-01 2015-04-11 10 500 MG EA
J1566 00944262004 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA (IGG) 10 G 2007-07-01 2015-06-21 20 500 MG EA
J1566 00944265503 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA (IGG) 5G 2007-07-01 2015-07-10 10 500 MG EA
J1566 00944265504 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA (IGG) 10 G 2007-07-01 2015-10-03 20 500 MG EA
J1566 00944265603 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA(IGG) 5 G 2013-01-24 2299-12-31 10 500 MG EA
J1566 00944265804 GAMMAGARD S-D IMMUNE GLOBULIN,GAMMA(IGG) 10 G 2013-01-24 2299-12-31 20 500 MG EA
J1567 00944270002 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 00944270003 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 00944270004 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 00944270005 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 00944270006 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 13533064512 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 13533064515 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 13533064520 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 13533064524 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 61953000301 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 61953000302 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 61953000303 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 61953000304 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 67467084301 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 67467084302 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 67467084303 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 67467084304 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 67467084305 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 68209084301 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 68209084302 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 68209084303 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 68209084304 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
9
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ1567 68516161201 VENOGLOBULIN-S IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 68516161301 VENOGLOBULIN-S IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 68516161401 VENOGLOBULIN-S IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2007-07-01 2007-12-31 0.1 500 MG EA
J1567 68516162201 VENOGLOBULIN-S IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 68516162301 VENOGLOBULIN-S IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 68516162401 VENOGLOBULIN-S IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2007-07-01 2007-12-31 0.2 500 MG EA
J1567 13533064571 GAMUNEX IMMUNE GLOB,GAM CAPRYLATE(IGG) 10 % 2007-07-01 2014-10-22 0.2 500 MG EA
J1568 67467084301 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 67467084302 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 67467084303 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 67467084304 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 67467084305 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 68209084301 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 68209084302 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 68209084303 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 68209084304 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 5 % 2008-01-01 2011-09-23 0.1 500 MG ML
J1568 68982085001 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 10 % 2015-01-09 2299-12-31 0.1 500 MG ML
J1568 68982085002 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 10 % 2015-01-09 2299-12-31 0.1 500 MG ML
J1568 68982085003 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 10 % 2015-01-09 2299-12-31 0.1 500 MG ML
J1568 68982085004 OCTAGAM IMMUNE GLOBULIN,G(IGG)/MALTOSE 10 % 2015-01-09 2299-12-31 0.1 500 MG ML
J1569 00944270002 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2008-01-01 2299-12-31 0.2 500 MG ML
J1569 00944270003 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2008-01-01 2299-12-31 0.2 500 MG ML
J1569 00944270004 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2008-01-01 2299-12-31 0.2 500 MG ML
J1569 00944270005 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2008-01-01 2299-12-31 0.2 500 MG ML
J1569 00944270006 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2008-01-01 2299-12-31 0.2 500 MG ML
J1569 00944270007 GAMMAGARD LIQUID IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2011-03-04 2299-12-31 0.2 500 MG ML
J1569 00944270008 GAMMAGARD LIQUID IMMUN GLOB G (IGG)/GLY/IGA 50+ 10 % 2015-04-14 2299-12-31 0.2 500 MG ML
J1569 00944270009 GAMMAGARD LIQUID IMMUN GLOB G (IGG)/GLY/IGA 50+ 10 % 2015-04-14 2299-12-31 0.2 500 MG ML
J1569 00944270010 GAMMAGARD LIQUID IMMUN GLOB G (IGG)/GLY/IGA 50+ 10 % 2015-04-14 2299-12-31 0.2 500 MG ML
J1569 00944270011 GAMMAGARD LIQUID IMMUN GLOB G (IGG)/GLY/IGA 50+ 10 % 2015-03-13 2299-12-31 0.2 500 MG ML
J1569 00944270012 GAMMAGARD LIQUID IMMUN GLOB G (IGG)/GLY/IGA 50+ 10 % 2015-03-13 2299-12-31 0.2 500 MG ML
J1569 00944270013 GAMMAGARD LIQUID IMMUN GLOB G (IGG)/GLY/IGA 50+ 10 % 2015-04-14 2299-12-31 0.2 500 MG ML
J1572 61953000301 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2008-07-27 0.1 500 MG ML
J1572 61953000302 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2010-03-17 0.1 500 MG ML
J1572 61953000303 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2011-05-26 0.1 500 MG ML
J1572 61953000304 FLEBOGAMMA IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2011-07-08 0.1 500 MG ML
J1572 64208823401 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2011-07-01 2012-05-25 0.1 500 MG ML
J1572 64208823402 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2011-07-01 2012-05-25 0.1 500 MG ML
J1572 64208823403 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2011-07-01 2012-05-25 0.1 500 MG ML
J1572 61953000400 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-12-30 2299-12-31 0.1 500 MG ML
J1572 61953000401 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2299-12-31 0.1 500 MG ML
J1572 61953000402 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2299-12-31 0.1 500 MG ML
J1572 61953000403 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2299-12-31 0.1 500 MG ML
J1572 61953000404 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2299-12-31 0.1 500 MG ML
J1572 61953000405 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 5 % 2008-01-01 2299-12-31 0.1 500 MG ML
J1572 61953000406 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-12-30 2299-12-31 0.1 500 MG ML
J1572 61953000407 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-12-30 2299-12-31 0.1 500 MG ML
J1572 61953000408 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-12-30 2299-12-31 0.1 500 MG ML
J1572 61953000409 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 5 % 2013-12-30 2299-12-31 0.1 500 MG ML
J1572 61953000501 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2011-02-08 2299-12-31 0.2 500 MG ML
J1572 61953000502 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2011-02-08 2299-12-31 0.2 500 MG ML
J1572 61953000503 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA (IGG) 10 % 2011-02-08 2299-12-31 0.2 500 MG ML
J1572 61953000504 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2013-12-27 2299-12-31 0.2 500 MG ML
J1572 61953000505 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2013-12-27 2299-12-31 0.2 500 MG ML
J1572 61953000506 FLEBOGAMMA DIF IMMUNE GLOBULIN,GAMMA(IGG) 10 % 2013-12-27 2299-12-31 0.2 500 MG ML
J1599 44206041603 CARIMUNE NF NANOFILTERED IMMUNE GLOBULIN,GAMMA (IGG) 3 G 2012-01-01 2015-06-03 6 500 MG EA
J1599 44206041706 CARIMUNE NF NANOFILTERED IMMUNE GLOBULIN,GAMMA (IGG) 6G 2012-01-01 2299-12-31 12 500 MG EA
J1599 44206041812 CARIMUNE NF NANOFILTERED IMMUNE GLOBULIN,GAMMA (IGG) 12G 2012-01-01 2299-12-31 24 500 MG EA
J1626 00004024208 KYTRIL GRANISETRON HCL/PF 100 MCG/ML 2007-07-01 2009-07-31 1 100 MCG ML
10
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ1626 00004024009 KYTRIL GRANISETRON HCL 1 MG/ML 2007-07-01 2009-12-15 10 100 MCG ML
J1626 00703787103 GRANISETRON HCL GRANISETRON HCL/PF 1 MG/ML(1) 2008-01-03 2010-10-19 10 100 MCG ML
J1626 66758003702 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2008-06-30 2010-11-16 1 100 MCG ML
J1626 00004023909 KYTRIL GRANISETRON HCL 1 MG/ML(1) 2007-07-01 2010-11-30 10 100 MCG ML
J1626 64679066201 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2008-04-25 2011-01-05 1 100 MCG ML
J1626 66860008106 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2008-08-18 2011-03-18 1 100 MCG ML
J1626 66860008206 GRANISETRON HCL GRANISETRON HCL/PF 1 MG/ML(1) 2008-08-18 2011-03-18 10 100 MCG ML
J1626 66860008301 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2009-12-17 2011-03-18 10 100 MCG ML
J1626 55390025010 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2008-07-29 2011-05-02 1 100 MCG ML
J1626 10019005303 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2007-12-31 2011-06-28 10 100 MCG ML
J1626 10019005314 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2007-12-31 2011-06-28 10 100 MCG ML
J1626 00703789102 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2008-01-03 2011-07-07 1 100 MCG ML
J1626 60505069200 GRANISETRON HCL GRANISETRON HCL 1 MG/ML(1) 2008-08-14 2011-10-13 10 100 MCG ML
J1626 60505069300 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2008-08-14 2011-10-13 10 100 MCG ML
J1626 60505076402 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2007-12-31 2011-10-13 1 100 MCG ML
J1626 17478054604 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2010-02-19 2012-11-30 10 100 MCG ML
J1626 17478054601 GRANISETRON HCL GRANISETRON HCL 1 MG/ML(1) 2010-02-19 2013-07-25 10 100 MCG ML
J1626 17478054701 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2010-02-19 2013-07-25 1 100 MCG ML
J1626 64679066102 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2008-07-01 2015-04-30 10 100 MCG ML
J1626 64679066103 GRANISETRON HCL GRANISETRON HCL/PF 1 MG/ML(1) 2008-07-01 2015-04-30 10 100 MCG ML
J1626 00143974410 GRANISETRON HCL GRANISETRON HCL 1 MG/ML(1) 2010-09-14 2299-12-31 10 100 MCG ML
J1626 00143974505 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2010-09-14 2299-12-31 10 100 MCG ML
J1626 00703789101 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2010-08-04 2299-12-31 1 100 MCG ML
J1626 00703797103 GRANISETRON HCL GRANISETRON HCL 1 MG/ML(1) 2008-01-03 2299-12-31 10 100 MCG ML
J1626 00703797301 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2008-06-30 2299-12-31 10 100 MCG ML
J1626 17478054602 GRANISETRON HCL GRANISETRON HCL 1 MG/ML(1) 2011-07-20 2299-12-31 10 100 MCG ML
J1626 17478054605 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2011-07-20 2299-12-31 10 100 MCG ML
J1626 25021077801 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2010-12-15 2299-12-31 1 100 MCG ML
J1626 25021077866 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2013-08-20 2299-12-31 1 100 MCG ML
J1626 25021077901 GRANISETRON HCL GRANISETRON HCL/PF 1 MG/ML(1) 2010-12-15 2299-12-31 10 100 MCG ML
J1626 25021078104 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2010-12-15 2299-12-31 10 100 MCG ML
J1626 63323031701 GRANISETRON HCL GRANISETRON HCL/PF 100 MCG/ML 2007-12-14 2299-12-31 1 100 MCG ML
J1626 63323031801 GRANISETRON HCL GRANISETRON HCL/PF 1 MG/ML(1) 2008-06-25 2299-12-31 10 100 MCG ML
J1626 63323031904 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2008-06-25 2299-12-31 10 100 MCG ML
J1626 66758003501 GRANISETRON HCL GRANISETRON HCL 1 MG/ML(1) 2008-06-30 2299-12-31 10 100 MCG ML
J1626 66758003601 GRANISETRON HCL GRANISETRON HCL 1 MG/ML 2008-06-30 2299-12-31 10 100 MCG ML
J1630 55390044710 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2011-06-30 1 5 MG ML
J1630 50458025303 HALDOL DECANOATE 50 HALOPERIDOL DECANOATE 50 MG/ML 2010-07-02 2011-07-25 10 5 MG ML
J1630 50458025414 HALDOL DECANOATE 100 HALOPERIDOL DECANOATE 100 MG/ML 2010-07-21 2011-07-25 20 5 MG ML
J1630 00045025501 HALDOL HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2011-08-02 1 5 MG ML
J1630 55390044701 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2012-05-02 1 5 MG ML
J1630 00703704103 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2013-05-09 1 5 MG ML
J1630 00069011302 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2011-11-08 2014-01-01 1 5 MG ML
J1630 55390014701 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2015-09-05 1 5 MG ML
J1630 55390014710 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2015-09-05 1 5 MG ML
J1630 00703704101 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2299-12-31 1 5 MG ML
J1630 00703704104 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2010-07-16 2299-12-31 1 5 MG ML
J1630 00703704501 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2299-12-31 1 5 MG ML
J1630 10147091101 HALOPERIDOL HALOPERIDOL LACTATE 5 MG/ML 2011-07-07 2299-12-31 1 5 MG ML
J1630 25021080601 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2011-11-21 2299-12-31 1 5 MG ML
J1630 25021082310 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2011-11-21 2299-12-31 1 5 MG ML
J1630 50458025501 HALDOL HALOPERIDOL LACTATE 5 MG/ML 2010-08-02 2299-12-31 1 5 MG ML
J1630 63323047401 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2299-12-31 1 5 MG ML
J1630 63323047410 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2007-07-01 2299-12-31 1 5 MG ML
J1630 67457042600 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2014-04-04 2299-12-31 1 5 MG ML
J1630 67457042612 HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5 MG/ML 2014-04-04 2299-12-31 1 5 MG ML
J1631 00045025301 HALDOL DECANOATE 50 HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2011-06-24 1 50 MG ML
J1631 00045025303 HALDOL DECANOATE 50 HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2011-07-02 1 50 MG ML
J1631 00045025414 HALDOL DECANOATE 100 HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2011-07-21 2 50 MG ML
11
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ1631 60505602102 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-12-14 2011-12-31 2 50 MG ML
J1631 55390041201 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2012-05-02 1 50 MG ML
J1631 55390041205 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2012-05-02 1 50 MG ML
J1631 55390041301 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2012-05-02 2 50 MG ML
J1631 55390041305 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2012-05-02 2 50 MG ML
J1631 54868288900 HALDOL DECANOATE 50 HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2013-06-30 1 50 MG ML
J1631 54868288901 HALDOL DECANOATE 50 HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2013-06-30 1 50 MG ML
J1631 60505070201 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2015-01-31 1 50 MG ML
J1631 60505070301 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2015-01-31 2 50 MG ML
J1631 60505602002 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2008-01-30 2015-02-28 1 50 MG ML
J1631 53150041510 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2013-05-21 2015-07-23 1 50 MG ML
J1631 53150048905 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2013-05-21 2015-07-23 2 50 MG ML
J1631 53150048501 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2013-05-21 2015-09-22 2 50 MG ML
J1631 53150048505 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2013-05-21 2015-09-22 2 50 MG ML
J1631 53150042201 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2013-05-13 2016-04-30 1 50 MG ML
J1631 53150042205 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2013-05-21 2016-04-30 1 50 MG ML
J1631 00703701103 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2299-12-31 1 50 MG ML
J1631 00703701103 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2299-12-31 1 50 MG ML
J1631 00703701301 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2299-12-31 1 50 MG ML
J1631 00703702103 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2299-12-31 2 50 MG ML
J1631 00703702301 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2299-12-31 2 50 MG ML
J1631 10147092103 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2011-11-08 2299-12-31 1 50 MG ML
J1631 10147092205 HALOPERIDOL DECANOATE 100 HALOPERIDOL DECANOATE 100 MG/ML 2011-07-07 2299-12-31 2 50 MG ML
J1631 50458025303 HALDOL DECANOATE 50 HALOPERIDOL DECANOATE 50 MG/ML 2011-07-26 2299-12-31 1 50 MG ML
J1631 50458025414 HALDOL DECANOATE 100 HALOPERIDOL DECANOATE 100 MG/ML 2011-07-26 2299-12-31 2 50 MG ML
J1631 63323046901 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2299-12-31 1 50 MG ML
J1631 63323046905 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2007-07-01 2299-12-31 1 50 MG ML
J1631 63323047101 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2299-12-31 2 50 MG ML
J1631 63323047105 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2007-07-01 2299-12-31 2 50 MG ML
J1631 67457038100 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2014-07-24 2299-12-31 2 50 MG ML
J1631 67457038158 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2014-07-23 2299-12-31 2 50 MG ML
J1631 67457038200 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2013-08-21 2299-12-31 1 50 MG ML
J1631 67457038258 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2013-08-21 2299-12-31 1 50 MG ML
J1631 67457040900 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2014-09-23 2299-12-31 2 50 MG ML
J1631 67457040913 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 MG/ML 2014-09-22 2299-12-31 2 50 MG ML
J1631 67457041000 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2013-08-21 2299-12-31 1 50 MG ML
J1631 67457041013 HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML 2013-08-21 2299-12-31 1 50 MG ML
J1725 64011024301 MAKENA HYDROXYPROGESTERONE CAPROATE 250 MG/ML 2012-01-01 2299-12-31 250 1 MG ML
J1740 00004018809 BONIVA IBANDRONATE SODIUM 3MG/3ML 2007-07-01 2013-09-30 1 1 MG ML
J1740 00004019109 BONIVA IBANDRONATE SODIUM 3 MG/3 ML 2011-11-08 2299-12-31 1 1 MG ML
J1740 25021082273 IBANDRONATE SODIUM IBANDRONATE SODIUM 3 MG/3 ML 2014-09-03 2299-12-31 1 1 MG ML
J1740 25021082761 IBANDRONATE SODIUM IBANDRONATE SODIUM 3 MG/3 ML 2014-09-02 2299-12-31 1 1 MG ML
J1740 62756021840 IBANDRONATE SODIUM IBANDRONATE SODIUM 3 MG/3 ML 2014-03-05 2299-12-31 1 1 MG ML
J1740 67457052433 IBANDRONATE SODIUM IBANDRONATE SODIUM 3 MG/3 ML 2014-09-02 2299-12-31 1 1 MG ML
J1743 54092070001 ELAPRASE IDURSULFASE 6MG/3ML 2012-08-25 2299-12-31 2 1 MG ML
J1744 54092070202 FIRAZYR ICATIBANT 30 MG/3ML 2013-01-01 2299-12-31 10 1 MG ML
J1744 54092070203 FIRAZYR ICATIBANT 30 MG/3ML 2013-01-01 2299-12-31 10 1 MG ML
J1745 57894003001 REMICADE INFLIXIMAB 100 MG 2007-07-01 2299-12-31 10 10 MG EA
J1750 54868431900 INFED IRON DEXTRAN COMPLEX 50 MG/ML 2009-01-01 2009-12-15 1 50 MG ML
J1750 00517013410 DEXFERRUM IRON DEXTRAN COMPLEX 50 MG/ML 2009-01-01 2016-05-06 1 50 MG ML
J1750 00517023410 DEXFERRUM IRON DEXTRAN COMPLEX 50 MG/ML 2009-01-01 2016-05-06 1 50 MG ML
J1750 52544093102 INFED IRON DEXTRAN COMPLEX 50 MG/ML 2009-01-01 2299-12-31 1 50 MG ML
J1750 52544093107 INFED IRON DEXTRAN COMPLEX 50 MG/ML 2011-12-06 2299-12-31 1 50 MG ML
J1756 00517231005 VENOFER IRON SUCROSE COMPLEX 200MG/10ML 2012-08-25 2299-12-31 20 1 MG ML
J1756 00517232510 VENOFER IRON SUCROSE COMPLEX 50MG/2.5ML 2012-08-25 2299-12-31 20 1 MG ML
J1756 00517234010 VENOFER IRON SUCROSE COMPLEX 100MG/5ML 2012-08-25 2299-12-31 20 1 MG ML
J1756 00517234025 VENOFER IRON SUCROSE COMPLEX 100MG/5ML 2012-08-25 2299-12-31 20 1 MG ML
J1756 00517234099 VENOFER IRON SUCROSE COMPLEX 100 MG/5ML 2014-07-11 2299-12-31 20 1 MG ML
J1756 49230053010 VENOFER IRON SUCROSE COMPLEX 50MG/2.5ML 2012-08-25 2299-12-31 20 1 MG ML
12
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ1756 49230053025 VENOFER IRON SUCROSE COMPLEX 50MG/2.5ML 2012-08-25 2299-12-31 20 1 MG ML
J1756 49230053410 VENOFER IRON SUCROSE COMPLEX 100MG/5ML 2012-08-25 2299-12-31 20 1 MG ML
J1756 49230053425 VENOFER IRON SUCROSE COMPLEX 100MG/5ML 2012-08-25 2299-12-31 20 1 MG ML
J1785 58468198301 CEREZYME IMIGLUCERASE 200 UNITS 2010-03-03 2010-12-31 200 1 UNITS EA
J1785 58468466301 CEREZYME IMIGLUCERASE 400 UNITS 2010-03-03 2010-12-31 400 1 UNITS EA
J1786 58468198301 CEREZYME IMIGLUCERASE 200 UNITS 2011-01-01 2012-03-31 20 10 UNITS EA
J1786 58468466301 CEREZYME IMIGLUCERASE 400 UNITS 2011-01-01 2299-12-31 40 10 UNITS EA
J1835 50458029801 SPORANOX ITRACONAZOLE 250 MG 2007-07-01 2009-02-28 5 50 MG EA
J1930 15054006001 SOMATULINE DEPOT LANREOTIDE ACETATE 60 MG/0.2 ML 2015-01-02 2299-12-31 300 1 MG ML
J1930 15054009001 SOMATULINE DEPOT LANREOTIDE ACETATE 90 MG/0.3 ML 2007-10-01 2299-12-31 300 1 MG ML
J1930 15054012001 SOMATULINE DEPOT LANREOTIDE ACETATE 120 MG/0.5 ML 2009-11-25 2299-12-31 240 1 MG ML
J1930 15054106003 SOMATULINE DEPOT LANREOTIDE ACETATE 60 MG/0.2 ML 2015-01-02 2299-12-31 300 1 MG ML
J1930 15054109003 SOMATULINE DEPOT LANREOTIDE ACETATE 90 MG/0.3 ML 2015-01-02 2299-12-31 300 1 MG ML
J1930 15054112003 SOMATULINE DEPOT LANREOTIDE ACETATE 120 MG/0.5 ML 2015-01-02 2299-12-31 240 1 MG ML
J1931 58468007001 ALDURAZYME LARONIDASE 2.9 MG/5ML 2007-07-01 2299-12-31 5.8 0.1 MG ML
J1950 00300361224 LUPRON LEUPROLIDE ACETATE 1MG/0.2ML 2009-01-01 2009-10-27 0.266 3.75 MG EA
J1950 00300361228 LUPRON LEUPROLIDE ACETATE 1MG/0.2ML 2009-01-01 2010-07-24 0.266 3.75 MG EA
J1950 00300210801 LUPRON DEPOT-PED LEUPROLIDE ACETATE 7.5 MG 2009-01-01 2010-08-27 2 3.75 MG EA
J1950 00300228201 LUPRON DEPOT-PED LEUPROLIDE ACETATE 11.25MG 2009-01-01 2010-08-27 3 3.75 MG EA
J1950 00300244001 LUPRON DEPOT-PED LEUPROLIDE ACETATE 15 MG 2009-01-01 2010-08-27 4 3.75 MG EA
J1950 00300334601 LUPRON DEPOT LEUPROLIDE ACETATE 22.5 MG 2009-01-01 2010-08-27 6 3.75 MG EA
J1950 00300364101 LUPRON DEPOT LEUPROLIDE ACETATE 3.75 MG 2007-07-01 2010-08-27 1 3.75 MG EA
J1950 00300364201 LUPRON DEPOT LEUPROLIDE ACETATE 7.5 MG 2009-01-01 2010-08-27 2 3.75 MG EA
J1950 00300366301 LUPRON DEPOT LEUPROLIDE ACETATE 11.25MG 2007-07-01 2010-08-27 3 3.75 MG EA
J1950 00300368301 LUPRON DEPOT LEUPROLIDE ACETATE 30 MG 2009-01-01 2010-08-27 8 3.75 MG EA
J1950 00074347303 LUPRON DEPOT LEUPROLIDE ACETATE 45 MG 2011-06-17 2011-06-17 12 3.75 MG EA
J1950 00024022205 ELIGARD LEUPROLIDE ACETATE 22.5 MG 2009-01-01 2011-09-23 6 3.75 MG EA
J1950 00024060545 ELIGARD LEUPROLIDE ACETATE 45 MG 2009-01-01 2011-09-23 12 3.75 MG EA
J1950 00024061030 ELIGARD LEUPROLIDE ACETATE 30 MG 2009-01-01 2011-09-23 8 3.75 MG EA
J1950 00024079375 ELIGARD LEUPROLIDE ACETATE 7.5 MG 2009-01-01 2011-09-23 2 3.75 MG EA
J1950 00185740085 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2009-12-21 2011-09-23 0.266 3.75 MG EA
J1950 00703401418 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2009-01-26 2011-09-23 0.266 3.75 MG EA
J1950 41616093640 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2009-03-27 2011-09-23 0.266 3.75 MG EA
J1950 00074210803 LUPRON DEPOT-PED LEUPROLIDE ACETATE 7.5 MG 2009-08-03 2299-12-31 2 3.75 MG EA
J1950 00074228203 LUPRON DEPOT-PED LEUPROLIDE ACETATE 11.25MG 2009-04-03 2299-12-31 3 3.75 MG EA
J1950 00074244003 LUPRON DEPOT-PED LEUPROLIDE ACETATE 15 MG 2009-04-17 2299-12-31 4 3.75 MG EA
J1950 00074334603 LUPRON DEPOT LEUPROLIDE ACETATE 22.5 MG 2009-04-02 2299-12-31 6 3.75 MG EA
J1950 00074364103 LUPRON DEPOT LEUPROLIDE ACETATE 3.75 MG 2009-04-13 2299-12-31 1 3.75 MG EA
J1950 00074364203 LUPRON DEPOT LEUPROLIDE ACETATE 7.5 MG 2009-03-25 2299-12-31 2 3.75 MG EA
J1950 00074366303 LUPRON DEPOT LEUPROLIDE ACETATE 11.25MG 2009-05-21 2299-12-31 3 3.75 MG EA
J1950 00074368303 LUPRON DEPOT LEUPROLIDE ACETATE 30 MG 2009-04-17 2299-12-31 8 3.75 MG EA
J1950 00074377903 LUPRON DEPOT-PED LEUPROLIDE ACETATE 11.25 MG 2011-11-08 2299-12-31 3 3.75 MG EA
J1950 00074969403 LUPRON DEPOT-PED LEUPROLIDE ACETATE 30 MG 2011-11-08 2299-12-31 8 3.75 MG EA
J2212 65649055305 RELISTOR METHYLNALTREXONE 12 MG/0.6 ML 2013-01-01 2015-09-30 180 0.1 MG ML
J2212 65649055102 RELISTOR METHYLNALTREXONE 12 MG/0.6 ML 2013-01-01 2299-12-31 180 0.1 MG ML
J2212 65649055103 RELISTOR METHYLNALTREXONE 12 MG/0.6 ML 2013-01-01 2299-12-31 180 0.1 MG ML
J2212 65649055107 RELISTOR METHYLNALTREXONE 12 MG/0.6 ML 2013-04-19 2299-12-31 180 0.1 MG ML
J2212 65649055204 RELISTOR METHYLNALTREXONE 8 MG/0.4 ML 2013-04-19 2299-12-31 180 0.1 MG ML
J2278 59075072010 PRIALT ZICONOTIDE ACETATE 100 MCG/ML 2007-07-01 2012-01-31 100 1 MCG ML
J2278 59075072210 PRIALT ZICONOTIDE ACETATE 100 MCG/ML 2007-07-01 2012-01-31 100 1 MCG ML
J2278 59075072310 PRIALT ZICONOTIDE ACETATE 25 MCG/ML 2007-07-01 2012-01-31 25 1 MCG ML
J2278 18860072010 PRIALT ZICONOTIDE ACETATE 100 MCG/ML 2011-02-08 2299-12-31 100 1 MCG ML
J2278 18860072210 PRIALT ZICONOTIDE ACETATE 100 MCG/ML 2011-02-08 2299-12-31 100 1 MCG ML
J2278 18860072310 PRIALT ZICONOTIDE ACETATE 25 MCG/ML 2011-02-08 2299-12-31 25 1 MCG ML
J2323 59075073015 TYSABRI NATALIZUMAB 300MG/15ML 2008-01-01 2015-04-01 20 1 MG ML
J2323 64406000801 TYSABRI NATALIZUMAB 300MG/15ML 2013-08-01 2299-12-31 20 1 MG ML
J2325 65847020525 NATRECOR NESIRITIDE 1.5 MG 2007-07-01 2299-12-31 15 0.1 MG EA
J2353 00078034061 SANDOSTATIN LAR OCTREOTIDE ACETATE 10 MG 2014-11-25 2299-12-31 10 1 MG EA
J2353 00078034161 SANDOSTATIN LAR OCTREOTIDE ACETATE 20 MG 2014-11-25 2299-12-31 20 1 MG EA
13
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ2353 00078034261 SANDOSTATIN LAR OCTREOTIDE ACETATE 30 MG 2014-11-25 2299-12-31 30 1 MG EA
J2353 00078064661 SANDOSTATIN LAR DEPOT OCTREOTIDE ACETATE,MI-SPHERES 10 MG 2015-04-14 2299-12-31 10 1 MG EA
J2353 00078064681 SANDOSTATIN LAR DEPOT OCTREOTIDE ACETATE,MI-SPHERES 10 MG 2015-04-10 2299-12-31 10 1 MG EA
J2353 00078064761 SANDOSTATIN LAR DEPOT OCTREOTIDE ACETATE,MI-SPHERES 20 MG 2015-04-14 2299-12-31 20 1 MG EA
J2353 00078064781 SANDOSTATIN LAR DEPOT OCTREOTIDE ACETATE,MI-SPHERES 20 MG 2015-04-10 2299-12-31 20 1 MG EA
J2353 00078064861 SANDOSTATIN LAR DEPOT OCTREOTIDE ACETATE,MI-SPHERES 30 MG 2015-04-14 2299-12-31 30 1 MG EA
J2353 00078064881 SANDOSTATIN LAR DEPOT OCTREOTIDE ACETATE,MI-SPHERES 30 MG 2015-04-10 2299-12-31 30 1 MG EA
J2355 58394000402 NEUMEGA OPRELVEKIN 5 MG 2007-07-01 2008-06-15 1 5 MG EA
J2355 58394000401 NEUMEGA OPRELVEKIN 5 MG 2007-07-01 2010-09-02 1 5 MG EA
J2355 58394000408 NEUMEGA OPRELVEKIN 5 MG 2008-08-26 2299-12-31 1 5 MG EA
J2355 58394010408 NEUMEGA OPRELVEKIN 5 MG 2015-07-31 2299-12-31 1 5 MG EA
J2357 50242004062 XOLAIR OMALIZUMAB 150 MG 2010-01-01 2299-12-31 30 5 MG EA
J2358 00002763511 ZYPREXA RELPREVV OLANZAPINE PAMOATE 210 MG 2012-01-01 2299-12-31 210 1 MG EA
J2358 00002763611 ZYPREXA RELPREVV OLANZAPINE PAMOATE 300 MG 2012-01-01 2299-12-31 300 1 MG EA
J2358 00002763711 ZYPREXA RELPREVV OLANZAPINE PAMOATE 405 MG 2012-01-01 2299-12-31 405 1 MG EA
J2358 00002765801 ZYPREXA RELPREVV OLANZAPINE PAMOATE 210 MG 2013-09-03 2299-12-31 210 1 MG EA
J2358 00002765901 ZYPREXA RELPREVV OLANZAPINE PAMOATE 300 MG 2013-09-03 2299-12-31 300 1 MG EA
J2358 00002766001 ZYPREXA RELPREVV OLANZAPINE PAMOATE 405 MG 2013-09-03 2299-12-31 405 1 MG EA
J2405 00173046100 ZOFRAN IN DEXTROSE ONDANSETRON HCL/D5W/PF 32MG/50ML 2007-07-01 2009-11-18 0.64 1 MG ML
J2405 54868450900 ZOFRAN ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2009-12-15 2 1 MG ML
J2405 00409475561 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2010-01-01 2 1 MG ML
J2405 00409475501 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2010-04-01 2 1 MG ML
J2405 00781305714 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2010-05-01 2 1 MG ML
J2405 00781305780 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2010-06-01 2 1 MG ML
J2405 61703024407 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2010-06-30 2 1 MG ML
J2405 61703024522 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2010-06-30 2 1 MG ML
J2405 66860008706 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2008-08-18 2011-03-18 2 1 MG ML
J2405 66860008801 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2008-08-19 2011-03-18 2 1 MG ML
J2405 00409475562 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-10-01 2011-04-01 2 1 MG ML
J2405 00069070012 ONDANSETRON HCL IN DEXTROSE ONDANSETRON HCL/D5W/PF 32MG/50ML 2009-11-24 2011-05-17 0.64 1 MG ML
J2405 25021077650 ONDANSETRON HCL IN DEXTROSE ONDANSETRON HCL/D5W/PF 32MG/50ML 2009-04-15 2011-06-30 0.64 1 MG ML
J2405 55390030710 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2011-06-30 2 1 MG ML
J2405 00409475502 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-08-24 2011-08-01 2 1 MG ML
J2405 00703722102 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2011-08-12 2 1 MG ML
J2405 00173044202 ZOFRAN ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2011-10-11 2 1 MG ML
J2405 23360001602 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2008-10-07 2012-05-01 2 1 MG ML
J2405 23360001620 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2008-02-10 2012-05-01 2 1 MG ML
J2405 55390012110 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2012-05-02 2 1 MG ML
J2405 55390030701 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2012-05-02 2 1 MG ML
J2405 00143977106 ONDANSETRON HCL IN DEXTROSE ONDANSETRON HCL/D5W/PF 32MG/50ML 2009-02-09 2012-05-13 0.64 1 MG ML
J2405 00781301180 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2009-02-24 2012-07-20 2 1 MG ML
J2405 10019090501 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2012-11-09 2 1 MG ML
J2405 10019090502 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2009-06-24 2012-11-09 2 1 MG ML
J2405 10019090503 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2009-06-24 2012-11-09 2 1 MG ML
J2405 10019090517 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2012-11-09 2 1 MG ML
J2405 10019090604 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2009-06-24 2013-01-13 2 1 MG ML
J2405 10019090605 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2009-06-24 2013-01-13 2 1 MG ML
J2405 00069134005 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2012-01-10 2013-02-14 2 1 MG ML
J2405 10019090603 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2013-02-17 2 1 MG ML
J2405 10019090663 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2013-02-17 2 1 MG ML
J2405 00069134002 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2011-03-10 2013-03-14 2 1 MG ML
J2405 00409112012 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2012-04-01 2013-03-14 2 1 MG ML
J2405 00641608001 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2011-11-11 2013-03-14 2 1 MG ML
J2405 00641608025 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2011-11-09 2013-03-14 2 1 MG ML
J2405 00143989105 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2013-04-10 2 1 MG ML
J2405 65293037302 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2012-12-06 2013-04-29 2 1 MG ML
J2405 65293037420 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2012-12-20 2013-04-29 2 1 MG ML
J2405 00409112062 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2013-05-10 2 1 MG ML
J2405 00338176241 ONDANSETRON IN SODIUM CHLORIDE ONDANSETRON/SOD CL/PF 32MG/50ML 2007-07-01 2013-07-25 0.64 1 MG ML
14
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ2405 00703723939 ONDANSETRON HCL IN DEXTROSE ONDANSETRON HCL/D5W/PF 32MG/50ML 2007-07-01 2013-11-29 0.64 1 MG ML
J2405 00409476013 ONDANSETRON HCL IN DEXTROSE ONDANSETRON HCL/D5W/PF 32MG/50ML 2007-07-01 2013-12-04 0.64 1 MG ML
J2405 00409476024 ONDANSETRON HCL IN DEXTROSE ONDANSETRON HCL/D5W/PF 32MG/50ML 2009-12-10 2013-12-04 0.64 1 MG ML
J2405 55390023401 ONDANSETRON HCL IN DEXTROSE ONDANSETRON HCL/D5W/PF 32 MG/50ML 2012-07-02 2013-12-04 0.64 1 MG ML
J2405 00069134016 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2012-01-10 2014-01-01 2 1 MG ML
J2405 64679072601 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2014-08-19 2 1 MG ML
J2405 64679072701 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2014-08-19 2 1 MG ML
J2405 60505074401 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2015-01-31 2 1 MG ML
J2405 60505074406 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2015-01-31 2 1 MG ML
J2405 00143989001 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 00143989125 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2011-04-07 2299-12-31 2 1 MG ML
J2405 00173044200 ZOFRAN ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 00409112011 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2015-04-20 2299-12-31 2 1 MG ML
J2405 00409475503 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2009-01-01 2299-12-31 2 1 MG ML
J2405 00409475518 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-06-19 2299-12-31 2 1 MG ML
J2405 00409475563 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2008-10-16 2299-12-31 2 1 MG ML
J2405 00409475901 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 00641607801 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2011-11-11 2299-12-31 2 1 MG ML
J2405 00641607825 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2011-11-09 2299-12-31 2 1 MG ML
J2405 00641607901 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2012-02-17 2299-12-31 2 1 MG ML
J2405 00703722101 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2012-10-17 2299-12-31 2 1 MG ML
J2405 00703722104 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 00703722601 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 00703722603 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 00781301072 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2009-01-01 2299-12-31 2 1 MG ML
J2405 00781301095 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2009-01-01 2299-12-31 2 1 MG ML
J2405 23155016831 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2012-08-01 2299-12-31 2 1 MG ML
J2405 23155019631 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2014-04-03 2299-12-31 2 1 MG ML
J2405 23155019642 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-03-01 2299-12-31 2 1 MG ML
J2405 23155019643 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-06-19 2299-12-31 2 1 MG ML
J2405 23155037731 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2014-06-12 2299-12-31 2 1 MG ML
J2405 23155037831 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-06-19 2299-12-31 2 1 MG ML
J2405 23155037841 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-06-19 2299-12-31 2 1 MG ML
J2405 23155037842 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-06-19 2299-12-31 2 1 MG ML
J2405 25021077702 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2012-11-19 2299-12-31 2 1 MG ML
J2405 25021078220 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2012-08-29 2299-12-31 2 1 MG ML
J2405 55150012502 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-04-02 2299-12-31 2 1 MG ML
J2405 55150012620 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2013-04-02 2299-12-31 2 1 MG ML
J2405 55390012101 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 62756018101 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 62756018201 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 63323037302 ONDANSETRON HCL ONDANSETRON HCL/PF 4MG/2ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 63323037420 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2007-07-01 2299-12-31 2 1 MG ML
J2405 65293037325 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2012-12-01 2299-12-31 2 1 MG ML
J2405 65293037401 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2012-12-01 2299-12-31 2 1 MG ML
J2405 67457044000 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-06-19 2299-12-31 2 1 MG ML
J2405 67457044022 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-06-19 2299-12-31 2 1 MG ML
J2405 67457044120 ONDANSETRON HCL ONDANSETRON HCL 2 MG/ML 2014-12-22 2299-12-31 2 1 MG ML
J2405 76045010320 ONDANSETRON HCL ONDANSETRON HCL/PF 4 MG/2 ML 2013-08-20 2299-12-31 2 1 MG ML
J2407 65293001501 ORBACTIV ORITAVANCIN DIPHOSPHATE 400 MG 2016-01-01 2299-12-31 40 10 MG EA
J2407 65293001503 ORBACTIV ORITAVANCIN DIPHOSPHATE 400 MG 2016-01-01 2299-12-31 40 10 MG EA
J2425 55513052001 KEPIVANCE PALIFERMIN 6.25 MG 2007-07-01 2011-09-10 125 50 MCG EA
J2425 55513052006 KEPIVANCE PALIFERMIN 6.25 MG 2007-07-01 2011-09-10 125 50 MCG EA
J2425 66658011201 KEPIVANCE PALIFERMIN 6.25 MG 2012-08-07 2299-12-31 125 50 MCG EA
J2425 66658011203 KEPIVANCE PALIFERMIN 6.25 MG 2012-07-31 2299-12-31 125 50 MCG EA
J2425 66658011206 KEPIVANCE PALIFERMIN 6.25 MG 2010-09-10 2299-12-31 125 50 MCG EA
J2426 50458056001 INVEGA SUSTENNA PALIPERIDONE PALMITATE 39MG/0.25 ML 2012-01-01 2299-12-31 156 1 MG ML
J2426 50458056101 INVEGA SUSTENNA PALIPERIDONE PALMITATE 78MG/0.5 ML 2012-01-01 2299-12-31 156 1 MG ML
J2426 50458056201 INVEGA SUSTENNA PALIPERIDONE PALMITATE 117MG/0.75 ML 2012-01-01 2299-12-31 156 1 MG ML
15
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ2426 50458056301 INVEGA SUSTENNA PALIPERIDONE PALMITATE 156 MG/ML 2012-01-01 2299-12-31 156 1 MG ML
J2426 50458056401 INVEGA SUSTENNA PALIPERIDONE PALMITATE 234 MG/1.5 ML 2012-01-01 2299-12-31 156 1 MG ML
J2469 58063079737 ALOXI PALONOSETRON HCL 0.075/1.5 2008-07-02 2010-03-01 2 25 MCG ML
J2469 58063079725 ALOXI PALONOSETRON HCL 0.25MG/5ML 2007-07-01 2010-04-01 2 25 MCG ML
J2469 62856079801 ALOXI PALONOSETRON HCL 0.075/1.5 2009-04-01 2011-04-01 2 25 MCG ML
J2469 62856079701 ALOXI PALONOSETRON HCL 0.25MG/5ML 2009-04-01 2299-12-31 2 25 MCG ML
J2503 68782000101 MACUGEN PEGAPTANIB SODIUM 0.3MG/90 2007-07-01 2009-06-20 11.11111 0.3 MG ML
J2503 68782000102 MACUGEN PEGAPTANIB SODIUM 0.3MG/90 2008-06-13 2299-12-31 11.11111 0.3 MG ML
J2504 57665000101 ADAGEN PEGADEMASE BOVINE 250 UNIT/1 2007-07-01 2299-12-31 10 25 UNITS ML
J2505 54868522900 NEULASTA PEGFILGRASTIM 6MG/0.6ML 2007-07-01 2009-12-15 1.66666 6 MG ML
J2505 55513019001 NEULASTA PEGFILGRASTIM 6MG/0.6ML 2007-07-01 2299-12-31 1.66666 6 MG ML
J2505 55513019201 NEULASTA PEGFILGRASTIM 6MG/0.6ML 2015-01-16 2299-12-31 1.66666 6 MG ML
J2507 54396080101 KRYSTEXXA PEGLOTICASE 8 MG/ML 2012-01-01 2016-06-01 8 1 MG ML
J2562 00024586201 MOZOBIL PLERIXAFOR 24MG/1.2ML 2013-12-12 2014-12-12 20 1 MG ML
J2562 58468014001 MOZOBIL PLERIXAFOR 20MG/ML 2012-08-25 2014-12-12 20 1 MG ML
J2704 00409469924 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00409469930 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00409469933 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00409469961 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00409469962 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00409469963 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00703285601 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00703285604 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00703285801 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00703285809 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00703285901 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 00703285903 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 25021060820 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 25021060850 PROPOFOL PROPOFOL 10 MG/ML 2015-03-23 2299-12-31 1 10 MG ML
J2704 25021060851 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026910 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026929 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026937 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026950 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026957 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026959 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026965 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026967 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026969 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026970 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026977 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026978 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323026994 DIPRIVAN PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323027025 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323027026 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323027050 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323027057 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323027065 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323027067 PROPOFOL PROPOFOL 10 MG/ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323029730 PROPOVEN PROPOFOL/PF 200MG/20ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323029750 PROPOVEN PROPOFOL/PF 500MG/50ML 2015-01-01 2299-12-31 1 10 MG ML
J2704 63323029766 PROPOVEN PROPOFOL/PF 1000MG/100 2015-01-01 2299-12-31 1 10 MG ML
J2778 50242008001 LUCENTIS RANIBIZUMAB 0.5 MG/0.05 ML 2011-01-01 2299-12-31 100 0.1 MG ML
J2778 50242008201 LUCENTIS RANIBIZUMAB 0.3MG/0.05 2012-08-10 2299-12-31 60 0.1 MG ML
J2780 00173036238 ZANTAC RANITIDINE HCL 50 MG/2 ML 2014-11-25 2015-12-01 1 25 MG ML
J2780 24987036210 ZANTAC RANITIDINE HCL 50 MG/2 ML 2014-12-01 2299-12-31 1 25 MG ML
J2780 24987036301 ZANTAC RANITIDINE HCL 25 MG/ML 2014-11-25 2299-12-31 1 25 MG ML
J2780 24987036401 ZANTAC RANITIDINE HCL 25 MG/ML 2014-11-25 2299-12-31 1 25 MG ML
J2780 68382042202 RANITIDINE HCL RANITIDINE HCL 50 MG/2 ML 2014-11-25 2299-12-31 1 25 MG ML
16
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ2780 68382042306 RANITIDINE HCL RANITIDINE HCL 25 MG/ML 2014-11-25 2299-12-31 1 25 MG ML
J2783 00024515010 ELITEK RASBURICASE 1.5 MG 2014-01-01 2299-12-31 3 0.5 MG EA
J2783 00024515011 ELITEK RASBURICASE 1.5 MG 2014-02-18 2299-12-31 3 0.5 MG EA
J2783 00024515175 ELITEK RASBURICASE 7.5 MG 2014-01-01 2299-12-31 15 0.5 MG EA
J2788 00562780806 MICRHOGAM RHO(D) IMMUNE GLOBULIN 50 MCG 2007-07-01 2009-12-15 1 50 MCG EA
J2788 00562780826 MICRHOGAM RHO(D) IMMUNE GLOBULIN 50 MCG 2007-07-01 2009-12-15 1 50 MCG EA
J2788 00562780601 MICRHOGAM PLUS RHO(D) IMMUNE GLOBULIN 50 MCG 2007-09-01 2010-07-01 1 50 MCG EA
J2788 00562780605 MICRHOGAM PLUS RHO(D) IMMUNE GLOBULIN 50 MCG 2007-09-01 2010-07-01 1 50 MCG EA
J2788 00562780625 MICRHOGAM PLUS RHO(D) IMMUNE GLOBULIN 50 MCG 2007-09-01 2010-07-01 1 50 MCG EA
J2788 00562780801 MICRHOGAM RHO(D) IMMUNE GLOBULIN 50 MCG 2007-07-01 2010-07-01 1 50 MCG EA
J2788 00562780600 MICRHOGAM ULTRA-FILTERED PLUS RHO(D) IMMUNE GLOBULIN 250 UNIT 2014-08-03 2299-12-31 1 50 MCG (250 UNITS) EA
J2788 13533066106 HYPERRHO S-D RHO(D) IMMUNE GLOBULIN 250 UNIT 2014-07-01 2299-12-31 1 50 MCG (250 UNITS) EA
J2788 13533066160 HYPERRHO S-D RHO(D) IMMUNE GLOBULIN 250 UNIT 2014-07-01 2299-12-31 1 50 MCG (250 UNITS) EA
J2790 00562780501 RHOGAM PLUS RHO(D) IMMUNE GLOBULIN 300 MCG 2007-09-01 2010-07-01 1 300 MCG EA
J2790 00562780505 RHOGAM PLUS RHO(D) IMMUNE GLOBULIN 300 MCG 2007-09-01 2010-07-01 1 300 MCG EA
J2790 00562780525 RHOGAM PLUS RHO(D) IMMUNE GLOBULIN 300 MCG 2007-09-01 2010-07-01 1 300 MCG EA
J2790 00562780701 RHOGAM RHO(D) IMMUNE GLOBULIN 300 MCG 2007-07-01 2010-07-01 1 300 MCG EA
J2790 00562780706 RHOGAM RHO(D) IMMUNE GLOBULIN 300 MCG 2007-07-01 2010-07-01 1 300 MCG EA
J2790 00562780726 RHOGAM RHO(D) IMMUNE GLOBULIN 300 MCG 2007-07-01 2010-07-01 1 300 MCG EA
J2790 00562780500 RHOGAM ULTRA-FILTERED PLUS RHO(D) IMMUNE GLOBULIN 1500 UNIT 2014-08-01 2299-12-31 1 300 MCG (1500 UNITS) EA
J2790 00562780501 RHOGAM PLUS RHO (D) IMMUNE GLOBULIN 1500 UNIT 2013-01-18 2299-12-31 1 300 MCG (1500 UNITS) EA
J2790 00562780505 RHOGAM PLUS RHO (D) IMMUNE GLOBULIN 1500 UNIT 2013-01-18 2299-12-31 1 300 MCG (1500 UNITS) EA
J2790 00562780525 RHOGAM PLUS RHO (D) IMMUNE GLOBULIN 1500 UNIT 2013-01-18 2299-12-31 1 300 MCG (1500 UNITS) EA
J2790 13533063102 HYPERRHO S-D RHO(D) IMMUNE GLOBULIN 300 MCG 2012-08-25 2299-12-31 1 300 MCG ML
J2790 13533063110 HYPERRHO S-D RHO(D) IMMUNE GLOBULIN 1500 UNIT 2014-10-15 2299-12-31 1 300 MCG (1500 UNITS) EA
J2790 13533063120 HYPERRHO S-D RHO(D) IMMUNE GLOBULIN 1500 UNIT 2014-10-24 2299-12-31 1 300 MCG (1500 UNITS) EA
J2791 00562780600 MICRHOGAM ULTRA-FILTERED PLUS RHO(D) IMMUNE GLOBULIN 250 UNIT 2014-01-08 2014-08-02 150 100 UNITS EA
J2791 44206030001 RHOPHYLAC RHO(D) IMMUNE GLOBULIN 300MCG/2ML 2008-01-01 2299-12-31 1.5 100 UNITS ML
J2791 44206030010 RHOPHYLAC RHO(D) IMMUNE GLOBULIN 300MCG/2ML 2008-01-01 2299-12-31 1.5 100 UNITS ML
J2791 44206030090 RHOPHYLAC RHO(D) IMMUNE GLOBULIN 1500/2 ML 2015-01-21 2299-12-31 7.5 100 UNITS ML
J2792 00944295002 WINRHO SDF RHO(D) IMMUNE GLOBULIN 600 UNIT 2007-07-01 2007-11-01 6 100 UNITS ML
J2792 00944295004 WINRHO SDF RHO(D) IMMUNE GLOBULIN 1500 UNIT 2007-07-01 2007-11-01 15 100 UNITS ML
J2792 00944295006 WINRHO SDF RHO(D) IMMUNE GLOBULIN 5000 UNIT 2007-07-01 2007-11-01 50 100 UNITS ML
J2792 00944296701 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 600/0.5ML 2007-07-01 2008-10-01 12 100 UNITS ML
J2792 13533063102 HYPERRHO S-D RHO(D) IMMUNE GLOBULIN 300 MCG 2007-07-01 2012-08-24 15 100 UNITS ML
J2792 13533063106 HYPERRHO S-D RHO(D) IMMUNE GLOBULIN 50 MCG 2007-07-01 2015-07-18 12.5 100 UNITS ML
J2792 00944296703 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 1500/1.3ML 2007-07-01 2299-12-31 11.53846 100 UNITS ML
J2792 00944296705 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 5000/4.4ML 2007-07-01 2299-12-31 11.3636 100 UNITS ML
J2792 00944296707 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 2500/2.2ML 2007-07-01 2299-12-31 11.3636 100 UNITS ML
J2792 00944296709 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 15000/13ML 2007-07-01 2299-12-31 11.53846 100 UNITS ML
J2792 53270300001 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 15000/13ML 2010-06-01 2299-12-31 11.53846 100 UNITS ML
J2792 53270310001 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 5000/4.4ML 2010-06-01 2299-12-31 11.3636 100 UNITS ML
J2792 53270330001 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 1500/1.3ML 2010-06-01 2299-12-31 11.53846 100 UNITS ML
J2792 53270350001 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE 2500/2.2ML 2010-06-01 2299-12-31 11.3636 100 UNITS ML
J2794 50458030611 RISPERDAL CONSTA RISPERIDONE MICROSPHERES 25 MG/2 ML 2007-07-01 2299-12-31 50 0.5 MG EA
J2794 50458030711 RISPERDAL CONSTA RISPERIDONE MICROSPHERES 37.5MG/2ML 2007-07-01 2299-12-31 75 0.5 MG EA
J2794 50458030811 RISPERDAL CONSTA RISPERIDONE MICROSPHERES 50 MG/2 ML 2007-07-01 2299-12-31 100 0.5 MG EA
J2794 50458030911 RISPERDAL CONSTA RISPERIDONE MICROSPHERES 12.5MG/2ML 2007-07-01 2299-12-31 25 0.5 MG EA
J2796 55513022101 NPLATE ROMIPLOSTIM 250 MCG 2010-01-01 2299-12-31 25 10 MCG EA
J2796 55513022201 NPLATE ROMIPLOSTIM 500 MCG 2010-01-01 2299-12-31 50 10 MCG EA
J2820 50419059505 LEUKINE SARGRAMOSTIM 500MCG/ML 2007-07-01 2009-01-24 10 50 MCG ML
J2820 54868318800 LEUKINE SARGRAMOSTIM 500MCG/ML 2007-07-01 2009-01-24 10 50 MCG ML
J2820 50419005030 LEUKINE SARGRAMOSTIM 500MCG/ML 2007-07-01 2012-10-31 10 50 MCG ML
J2820 50419000201 LEUKINE SARGRAMOSTIM 250 MCG 2007-07-01 2013-07-31 5 50 MCG EA
J2820 50419000233 LEUKINE SARGRAMOSTIM 250 MCG 2007-07-01 2013-07-31 5 50 MCG EA
J2820 58468018002 LEUKINE SARGRAMOSTIM 250 MCG 2010-03-10 2014-10-31 5 50 MCG EA
J2820 58468018101 LEUKINE SARGRAMOSTIM 500 MCG/ML 2011-11-04 2015-01-06 10 50 MCG ML
J2820 58468018102 LEUKINE SARGRAMOSTIM 500MCG/ML 2010-03-10 2015-01-06 10 50 MCG ML
J2820 00024584301 LEUKINE SARGRAMOSTIM 250 MCG 2013-12-04 2299-12-31 5 50 MCG EA
17
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ2820 00024584305 LEUKINE SARGRAMOSTIM 250 MCG 2013-10-31 2299-12-31 5 50 MCG EA
J2930 00409568423 A-METHAPRED METHYLPREDNISOLONE SOD SUCC 40 MG/ML 2014-11-25 2014-05-01 0.32 125 MG EA
J2930 00009069801 SOLU-MEDROL METHYLPREDNISOLONE SOD SUCC 1000 MG 2014-11-25 2299-12-31 8 125 MG EA
J2930 00009075801 SOLU-MEDROL METHYLPREDNISOLONE SOD SUCC 500 MG 2014-11-25 2299-12-31 4 125 MG EA
J2930 00009079601 SOLU-MEDROL METHYLPREDNISOLONE SOD SUCC 2 G 2014-11-25 2299-12-31 16 125 MG EA
J2930 63323025503 METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC 40 MG 2014-11-25 2299-12-31 0.32 125 MG EA
J2930 63323025803 METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC 125 MG 2014-11-25 2299-12-31 1 125 MG EA
J2930 63323026530 METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC 1000 MG 2014-11-25 2299-12-31 8 125 MG EA
J3060 00069010601 ELELYSO TALIGLUCERASE ALFA 200 UNITS 2014-01-01 2299-12-31 20 10 UNITS EA
J3095 52118000101 VIBATIV TELAVANCIN 750 MG 2015-01-01 2299-12-31 75 10 MG EA
J3095 52118000201 VIBATIV TELAVANCIN 250 MG 2015-01-01 2299-12-31 25 10 MG EA
J3240 58468003001 THYROGEN THYROTROPIN ALFA 1.1 MG 2014-11-05 2299-12-31 1 1.1 MG EA
J3240 58468184904 THYROGEN THYROTROPIN ALFA 1.1MG 2007-07-01 2299-12-31 1 1.1 MG EA
J3262 50242013501 ACTEMRA TOCILIZUMAB 80 MG/4 ML 2012-01-01 2299-12-31 20 1 MG ML
J3262 50242013601 ACTEMRA TOCILIZUMAB 200MG/10ML 2012-01-01 2299-12-31 20 1 MG ML
J3262 50242013701 ACTEMRA TOCILIZUMAB 400MG/20ML 2012-01-01 2299-12-31 20 1 MG ML
J3262 50242013801 ACTEMRA TOCILIZUMAB 162 MG/0.9 2013-10-28 2299-12-31 180 1 MG ML
J3300 00065054301 TRIESENCE TRIAMCINOLONE ACETONIDE/PF 40 MG/ML 2009-01-01 2299-12-31 1 1 MG EA
J3301 54643105500 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 20 MG/ML 2011-01-01 2010-03-01 2 10 MG ML
J3301 54643105600 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 20 MG/ML 2011-01-01 2010-03-01 2 10 MG ML
J3301 00781324375 TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 10 MG/ML 2010-01-01 2010-10-01 1 10 MG ML
J3301 00781324572 TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 40 MG/ML 2010-01-01 2010-10-01 4 10 MG ML
J3301 00781308475 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 5 MG/ML 2011-01-01 2012-05-25 0.5 10 MG ML
J3301 00781308571 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 20 MG/ML 2011-01-01 2012-05-25 2 10 MG ML
J3301 00781308575 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 20 MG/ML 2011-01-01 2012-05-25 2 10 MG ML
J3301 00003029305 KENALOG-40 TRIAMCINOLONE ACETONIDE 40 MG/ML 2010-01-01 2299-12-31 4 10 MG ML
J3301 00003029320 KENALOG-40 TRIAMCINOLONE ACETONIDE 40 MG/ML 2010-01-01 2299-12-31 4 10 MG ML
J3301 00003029328 KENALOG-40 TRIAMCINOLONE ACETONIDE 40 MG/ML 2010-01-01 2299-12-31 4 10 MG ML
J3301 00003049420 KENALOG-10 TRIAMCINOLONE ACETONIDE 10 MG/ML 2010-01-01 2299-12-31 1 10 MG ML
J3303 00781308475 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 5 MG/ML 2012-05-26 2299-12-31 1 5 MG ML
J3303 00781308571 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 20 MG/ML 2012-05-26 2299-12-31 4 5 MG ML
J3303 00781308575 ARISTOSPAN TRIAMCINOLONE HEXACETONIDE 20 MG/ML 2012-05-26 2299-12-31 4 5 MG ML
J3315 52544015376 TRELSTAR DEPOT TRIPTORELIN 3.75 MG 2007-07-01 2009-06-23 1 3.75 MG EA
J3315 52544015476 TRELSTAR LA TRIPTORELIN 11.25 MG 2007-07-01 2009-06-23 3 3.75 MG EA
J3315 52544009224 TRELSTAR TRIPTORELIN 22.5 MG 2011-04-21 2012-06-09 6 3.75 MG EA
J3315 52544018824 TRELSTAR TRIPTORELIN 11.25 MG 2011-04-21 2012-06-09 3 3.75 MG EA
J3315 52544018924 TRELSTAR TRIPTORELIN 3.75 MG 2011-04-21 2012-06-09 1 3.75 MG EA
J3315 52544009276 TRELSTAR TRIPTORELIN 22.5 MG 2010-04-15 2299-12-31 6 3.75 MG EA
J3315 52544015302 TRELSTAR DEPOT TRIPTORELIN 3.75 MG 2007-07-01 2299-12-31 1 3.75 MG EA
J3315 52544015402 TRELSTAR LA TRIPTORELIN 11.25 MG 2007-07-01 2299-12-31 3 3.75 MG EA
J3315 52544015602 TRELSTAR TRIPTORELIN 22.5 MG 2010-04-15 2299-12-31 6 3.75 MG EA
J3315 52544018876 TRELSTAR TRIPTORELIN 11.25 MG 2008-06-02 2299-12-31 3 3.75 MG EA
J3315 52544018976 TRELSTAR TRIPTORELIN 3.75 MG 2008-06-02 2299-12-31 1 3.75 MG EA
J3357 57894006003 STELARA USTEKINUMAB 45MG/0.5 ML 2012-01-01 2299-12-31 90 1 MG ML
J3357 57894006103 STELARA USTEKINUMAB 90MG/ML 2012-01-01 2299-12-31 90 1 MG ML
J3370 00409433201 VANCOMYCIN HCL VANCOMYCIN HCL 500 MG 2015-01-01 2299-12-31 1 500 MG EA
J3370 00409433249 VANCOMYCIN HCL VANCOMYCIN HCL 500 MG 2015-01-01 2015-12-31 1 500 MG EA
J3370 00409653401 VANCOMYCIN HCL VANCOMYCIN HCL 500 MG 2015-01-01 2299-12-31 1 500 MG EA
J3370 00409653449 VANCOMYCIN HCL VANCOMYCIN HCL 500 MG 2015-01-01 2015-04-30 1 500 MG EA
J3370 63323022110 VANCOMYCIN HCL VANCOMYCIN HCL 500 MG 2015-01-01 2299-12-31 1 500 MG EA
J3370 67457033950 VANCOMYCIN HCL VANCOMYCIN HCL 500 MG 2015-01-01 2299-12-31 1 500 MG EA
J3370 67457061110 VANCOMYCIN HCL VANCOMYCIN HCL 500 MG 2015-07-07 2299-12-31 1 500 MG EA
J3370 63323022116 VANCOMYCIN HCL VANCOMYCIN HCL 500MG 2015-08-27 2299-12-31 1 500 MG EA
J3380 64764030020 ENTYVIO VEDOLIZUMAB 300 MG 2016-01-01 2299-12-31 300 1 MG EA
J3385 54092070104 VPRIV VELAGLUCERASE ALFA 400 UNITS 2011-01-01 2299-12-31 4 100 UNITS EA
J3396 00078043761 VISUDYNE VERTEPORFIN 15 MG 2007-07-01 2012-11-30 150 0.1 MG EA
J3396 50236000115 VISUDYNE VERTEPORFIN 15 MG 2010-07-01 2014-09-03 150 0.1 MG EA
J3396 00187560015 VISUDYNE VERTEPORFIN 15 MG 2013-09-03 2299-12-31 150 0.1 MG EA
J3415 63323018001 PYRIDOXINE HCL PYRIDOXINE HCL 100 MG/ML 2007-07-01 2299-12-31 1 100 MG ML
18
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ3487 00078038725 ZOMETA ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/5ML 2012-08-18 2013-12-31 0.8 1 MG ML
J3487 00078059061 ZOMETA ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/100ML 2011-11-08 2013-12-31 0.04 1 MG ML
J3487 00143964201 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-07-15 2013-12-31 0.8 1 MG ML
J3487 23155017031 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-05-08 2013-12-31 0.8 1 MG ML
J3487 25021080166 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-03-04 2013-12-31 0.8 1 MG ML
J3487 25021082682 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/100ML 2013-08-06 2013-12-31 0.04 1 MG ML
J3487 42023015101 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-03-05 2013-12-31 0.8 1 MG ML
J3487 42023015101 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5ML 2013-03-05 2013-12-31 0.8 1 MG ML
J3487 43598033011 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-08-27 2013-12-31 0.8 1 MG ML
J3487 47335003540 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-03-04 2013-12-31 0.8 1 MG ML
J3487 53150087101 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-05-21 2013-12-31 0.8 1 MG ML
J3487 55111068507 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5ML 2013-03-04 2013-12-31 0.8 1 MG ML
J3487 55111068507 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-03-05 2013-12-31 0.8 1 MG ML
J3487 60505611000 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2013-10-04 2013-12-31 0.8 1 MG ML
J3488 00078043561 RECLAST ZOLEDRONIC ACID/MANNITOL/WATER 5MG/100ML 2008-01-01 2013-12-31 0.05 1 MG ML
J3488 23155018631 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2013-03-29 2013-12-31 0.05 1 MG ML
J3488 25021083082 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2013-03-02 2013-12-31 0.05 1 MG ML
J3488 42023016301 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2013-12-02 2013-12-31 0.05 1 MG ML
J3488 42023016301 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2013-12-02 2013-12-31 0.05 1 MG ML
J3488 43598033111 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2013-08-27 2013-12-31 0.05 1 MG ML
J3488 55111068852 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2013-04-03 2013-12-31 0.05 1 MG ML
J3488 42023016301 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2014-01-01 2014-01-01 0.05 1 MG ML
J3489 53150087101 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2016-01-27 0.8 1 MG ML
J3489 00078038725 ZOMETA ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/5ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 00078043561 RECLAST ZOLEDRONIC ACID/MANNITOL/WATER 5MG/100ML 2014-01-01 2299-12-31 0.05 1 MG ML
J3489 00078059061 ZOMETA ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/100ML 2014-01-01 2299-12-31 0.04 1 MG ML
J3489 00143964201 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 23155017031 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 23155018631 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2014-01-01 2299-12-31 0.05 1 MG ML
J3489 25021080166 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 25021082682 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/100ML 2014-01-01 2299-12-31 0.04 1 MG ML
J3489 25021083082 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2014-01-01 2299-12-31 0.05 1 MG ML
J3489 42023015101 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 42023015101 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 42023016301 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2014-01-01 2299-12-31 0.05 1 MG ML
J3489 42023016301 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2014-01-02 2299-12-31 0.05 1 MG ML
J3489 43598033011 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 43598033111 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2014-01-01 2299-12-31 0.05 1 MG ML
J3489 45963044055 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2015-01-13 2299-12-31 0.8 1 MG ML
J3489 47335003540 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 47335096241 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG 2014-01-01 2299-12-31 4 1 MG EA
J3489 55111068507 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 55111068507 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 55111068852 ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML 2014-01-01 2299-12-31 0.05 1 MG ML
J3489 60505611000 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2014-01-01 2299-12-31 0.8 1 MG ML
J3489 63323096198 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2015-01-27 2299-12-31 0.8 1 MG ML
J3489 67457039054 ZOLEDRONIC ACID ZOLEDRONIC ACID 4 MG/5 ML 2015-01-27 2299-12-31 0.8 1 MG ML
J3490 59730420401 NABI-HB HEPATITIS B IMMUNE GLOBULIN >312/ML 2007-07-01 2008-06-27 1 1 EA
J3490 59730420501 NABI-HB HEPATITIS B IMMUNE GLOBULIN >1560/5ML 2007-07-01 2008-06-27 1 1 EA
J3490 00065054301 TRIESENCE TRIAMCINOLONE ACETONIDE/PF 40 MG/ML 2008-07-01 2008-12-31 1 1 EA
J3490 63459039120 TREANDA BENDAMUSTINE HCL 100 MG 2008-03-31 2008-12-31 1 1 EA
J3490 13533063601 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 220 UNIT/1 2007-07-01 2009-12-15 1 1 EA
J3490 13533063602 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 220 UNIT/1 2007-07-01 2009-12-15 1 1 EA
J3490 13533063603 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 110/0.5ML 2007-07-01 2009-12-15 1 1 EA
J3490 13533063605 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 220/ML (5) 2007-07-01 2009-12-15 1 1 EA
J3490 49999042505 NABI-HB HEPATITIS B IMMUNE GLOBULIN >1560/5ML 2007-07-01 2009-12-15 1 1 EA
J3490 54569473900 NABI-HB HEPATITIS B IMMUNE GLOBULIN >1560/5ML 2007-07-01 2009-12-15 1 1 EA
J3490 59730420201 NABI-HB HEPATITIS B IMMUNE GLOBULIN >312/ML 2001-07-01 2009-12-15 1 1 EA
J3490 59730420301 NABI-HB HEPATITIS B IMMUNE GLOBULIN >1560/5ML 2007-07-01 2009-12-15 1 1 EA
19
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ3490 54092070104 VPRIV VELAGLUCERASE ALFA 400 UNITS 2010-03-03 2010-12-31 1 1 EA
J3490 30237890006 PROVENGE SIPULEUCEL-T/LACTATED RINGERS 50MM/250 2010-11-10 2012-04-10 1 1 EA
J3590 55513022101 NPLATE ROMIPLOSTIM 250 MCG 2008-08-25 2009-12-31 1 1 EA
J3590 55513022201 NPLATE ROMIPLOSTIM 500 MCG 2008-08-25 2009-12-31 1 1 EA
J3590 24856000100 JETREA OCRIPLASMIN/PF 2.5 MG/ML 2013-01-04 2013-12-31 5 1 ML
J3590 13533063601 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 220 UNIT/1 2009-12-16 2299-12-31 1 1 EA
J3590 13533063602 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 220 UNIT/1 2009-12-16 2299-12-31 1 1 EA
J3590 13533063603 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 110/0.5ML 2009-12-16 2299-12-31 1 1 EA
J3590 13533063605 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN 220/ML (5) 2009-12-16 2299-12-31 1 1 EA
J3590 59730420201 NABI-HB HEPATITIS B IMMUNE GLOBULIN >312/ML 2009-12-16 2299-12-31 1 1 EA
J3590 59730420301 NABI-HB HEPATITIS B IMMUNE GLOBULIN >1560/5ML 2009-12-16 2299-12-31 1 1 EA
J7040 00264400155 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2016-09-30 0.002 500 ML ML
J7040 00264780010 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7040 00264999910 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-12-01 2299-12-31 0.002 500 ML ML
J7040 00338004903 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7040 00338630403 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7040 00409798303 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7040 00409798330 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7040 00409798355 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7040 63323062351 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7040 63323062359 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.002 500 ML ML
J7050 00409158302 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2012-11-01 0.004 250 ML ML
J7050 00264780020 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.004 250 ML ML
J7050 00338004902 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.004 250 ML ML
J7050 00338630402 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.004 250 ML ML
J7050 00338954201 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-08-15 2299-12-31 0.004 250 ML ML
J7050 00409710102 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.004 250 ML ML
J7050 00409710104 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2015-01-22 2299-12-31 0.004 250 ML ML
J7050 00409798302 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.004 250 ML ML
J7050 00409798325 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.004 250 ML ML
J7050 00409798353 SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % 2014-11-25 2299-12-31 0.004 250 ML ML
J7178 63833891501 RIASTAP FIBRINOGEN 900-1300 MG 2013-01-01 2013-10-24 1 1 MG EA
J7178 63833089151 RIASTAP FIBRINOGEN 900-1300 MG 2013-01-01 2299-12-31 1 1 MG EA
J7180 63833051802 CORIFACT FACTOR XIII 1000-1600 2012-01-01 2299-12-31 1 1 UNIT EA
J7181 00169701301 TRETTEN FACTOR XIII A-SUBUNIT,RECOMB 2500 UNIT 2015-01-01 2299-12-31 1 1 UNIT EA
J7181 00169711311 TRETTEN FACTOR XIII A-SUBUNIT,RECOMB 2500 UNIT 2015-01-01 2299-12-31 1 1 UNIT EA
J7183 67467018101 WILATE AHF,HUMAN/VWF,HUMAN 450-450 2012-01-01 2299-12-31 1 1 UNIT EA
J7183 67467018102 WILATE AHF,HUMAN/VWF,HUMAN 900-900 2012-01-01 2299-12-31 1 1 UNIT EA
J7183 67467018201 WILATE AHF,HUMAN/VWF,HUMAN 500-500 2012-01-01 2299-12-31 1 1 UNIT EA
J7183 67467018202 WILATE AHF,HUMAN/VWF,HUMAN 1K-1K UNIT 2012-01-01 2299-12-31 1 1 UNIT EA
J7185 58394001201 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394001301 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394001401 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394001501 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 2000 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394001603 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 3000 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394002203 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394002303 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394002403 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7185 58394002503 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 2000 (+/-) 2012-05-26 2299-12-31 1 1 UNIT EA
J7186 68516460101 ALPHANATE AHF,HUMAN/VWF,HUMAN 250 (100) 2012-01-01 2299-12-31 1 1 UNIT EA
J7186 68516460201 ALPHANATE AHF,HUMAN/VWF,HUMAN 500 (200) 2012-01-01 2299-12-31 1 1 UNIT EA
J7186 68516460302 ALPHANATE AHF,HUMAN/VWF,HUMAN 1000 (400) 2012-01-01 2299-12-31 1 1 UNIT EA
J7186 68516460402 ALPHANATE AHF,HUMAN/VWF,HUMAN 1500 (600) 2012-01-01 2299-12-31 1 1 UNIT EA
J7186 68516460902 ALPHANATE ANTIHEMOPHILIC FACTOR/VWF 2000 (800) 2014-09-04 2299-12-31 1 1 UNIT EA
J7186 68516461002 ALPHANATE ANTIHEMOPHILIC FACTOR/VWF 2000 (800) 2014-09-04 2299-12-31 1 1 UNIT EA
J7187 00053761505 HUMATE-P AHF,HUMAN/VWF,HUMAN 250-600 2012-01-01 2012-09-12 1 1 UNIT EA
J7187 00053761510 HUMATE-P AHF,HUMAN/VWF,HUMAN 500-1200 U 2012-01-01 2012-11-17 1 1 UNIT EA
J7187 00053761520 HUMATE-P AHF,HUMAN/VWF,HUMAN 1000-2400 2012-01-01 2013-03-10 1 1 UNIT EA
J7187 63833061502 HUMATE-P AHF,HUMAN/VWF,HUMAN 250-600 2012-01-01 2299-12-31 1 1 UNIT EA
20
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ7187 63833061602 HUMATE-P AHF,HUMAN/VWF,HUMAN 500-1200 U 2012-01-01 2299-12-31 1 1 UNIT EA
J7187 63833061702 HUMATE-P AHF,HUMAN/VWF,HUMAN 1000-2400 2012-01-01 2299-12-31 1 1 UNIT EA
J7189 00169706001 NOVOSEVEN FACTOR VIIA,RECOMB(BHK CELLS) 1200MCG 2007-07-01 2012-07-01 1200 1 MCG EA
J7189 00169706101 NOVOSEVEN FACTOR VIIA,RECOMB(BHK CELLS) 2400MCG 2007-07-01 2012-07-01 2400 1 MCG EA
J7189 00169706201 NOVOSEVEN FACTOR VIIA,RECOMB(BHK CELLS) 4800 MCG 2007-07-01 2012-07-01 4800 1 MCG EA
J7189 00169701001 NOVOSEVEN RT FACTOR VIIA,RECOMB(BHK CELLS) 1 MG 2008-07-11 2014-06-01 1000 1 MCG EA
J7189 00169702001 NOVOSEVEN RT FACTOR VIIA,RECOMB(BHK CELLS) 2 MG 2008-07-11 2014-06-01 2000 1 MCG EA
J7189 00169704001 NOVOSEVEN RT COAGULATION FACTOR VIIA RECOMB 8 MG 2010-09-21 2014-06-01 8000 1 MCG EA
J7189 00169705001 NOVOSEVEN RT FACTOR VIIA,RECOMB(BHK CELLS) 5 MG 2008-07-11 2014-06-01 5000 1 MCG EA
J7189 00169720101 NOVOSEVEN RT COAGULATION FACTOR VIIA,RECOMB 1 MG 2013-04-26 2299-12-31 1000 1 MCG EA
J7189 00169720201 NOVOSEVEN RT COAGULATION FACTOR VIIA,RECOMB 2 MG 2013-04-26 2299-12-31 2000 1 MCG EA
J7189 00169720501 NOVOSEVEN RT COAGULATION FACTOR VIIA,RECOMB 5 MG 2013-04-26 2299-12-31 5000 1 MCG EA
J7189 00169720801 NOVOSEVEN RT COAGULATION FACTOR VIIA,RECOMB 8 MG 2013-04-26 2299-12-31 8000 1 MCG EA
J7190 00053765602 MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 500 (+/-) 2007-07-01 2007-12-28 1 1 UNIT EA
J7190 00026066550 KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 1000 (+/-) 2007-07-01 2009-12-15 1 1 UNIT EA
J7190 00053765601 MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 250 (+/-) 2007-07-01 2010-07-08 1 1 UNIT EA
J7190 00944293503 HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 801-1700 U 2007-07-01 2011-04-26 1 1 UNIT EA
J7190 00944293502 HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 401-800 U 2007-07-01 2011-08-27 1 1 UNIT EA
J7190 00944293504 HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 1701-2000 2007-07-01 2011-12-27 1 1 UNIT EA
J7190 00053765605 MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 1500 (+/-) 2007-07-01 2013-10-28 1 1 UNIT EA
J7190 00053765604 MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 1000 (+/-) 2007-07-01 2013-11-15 1 1 UNIT EA
J7190 13533066520 KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 250 (+/-) 2007-11-01 2013-12-31 1 1 UNIT EA
J7190 13533066530 KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 500 (+/-) 2007-11-01 2013-12-31 1 1 UNIT EA
J7190 13533066550 KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 1000 (+/-) 2007-11-01 2013-12-31 1 1 UNIT EA
J7190 76125050030 KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 500 (+/-) 2011-12-05 2014-08-01 1 1 UNIT EA
J7190 00053763302 MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 1000 (+/-) 2011-01-17 2299-12-31 1 1 UNIT EA
J7190 00053763402 MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 1500 (+/-) 2011-01-17 2299-12-31 1 1 UNIT EA
J7190 00944293001 HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 220-400 U 2008-06-25 2299-12-31 1 1 UNIT EA
J7190 00944293101 HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 401-800 U 2008-06-25 2299-12-31 1 1 UNIT EA
J7190 00944293201 HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 801-1700 U 2008-06-25 2299-12-31 1 1 UNIT EA
J7190 00944293301 HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 1701-2000 2008-06-25 2299-12-31 1 1 UNIT EA
J7190 00944394002 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN 220-400 2013-07-30 2299-12-31 1 1 UNIT EA
J7190 00944394202 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN 401-800 2013-07-30 2299-12-31 1 1 UNIT EA
J7190 00944394402 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN 801-1500 2013-07-30 2299-12-31 1 1 UNIT EA
J7190 00944394602 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN 1501-2000 2013-07-30 2299-12-31 1 1 UNIT EA
J7190 76125025020 KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 250 (+/-) 2011-12-05 2299-12-31 1 1 UNIT EA
J7190 76125066730 KOATE-DVI ANTIHEMOPHILIC FACTOR, HUMAN 500 (+/-) 2013-07-22 2299-12-31 1 1 UNIT EA
J7190 76125066750 KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 1000 (+/-) 2011-12-05 2299-12-31 1 1 UNIT EA
J7190 76125067250 KOATE-DVI ANTIHEMOPHILIC FACTOR, HUMAN 1000 (+/-) 2015-05-11 2299-12-31 1 1 UNIT EA
J7190 76125067351 KOATE-DVI ANTIHEMOPHILIC FACTOR, HUMAN 1000 (+/-) 2015-05-11 2299-12-31 1 1 UNIT EA
J7192 00944293801 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2007-07-01 2008-10-05 1 1 UNIT EA
J7192 00944293802 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2007-07-01 2008-10-05 1 1 UNIT EA
J7192 00944293803 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2007-07-01 2008-10-05 1 1 UNIT EA
J7192 58394000502 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2007-07-01 2010-04-09 1 1 UNIT EA
J7192 58394001102 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2007-07-01 2010-04-09 1 1 UNIT EA
J7192 58394000504 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2008-03-26 2010-05-31 1 1 UNIT EA
J7192 58394000602 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2007-07-01 2010-05-31 1 1 UNIT EA
J7192 58394000604 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2008-09-18 2010-05-31 1 1 UNIT EA
J7192 58394000702 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2007-07-01 2010-05-31 1 1 UNIT EA
J7192 58394000704 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2008-12-09 2010-05-31 1 1 UNIT EA
J7192 58394001104 REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2008-03-26 2010-05-31 1 1 UNIT EA
J7192 58394001201 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2008-07-10 2012-05-25 1 1 UNIT EA
J7192 58394001301 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2008-07-10 2012-05-25 1 1 UNIT EA
J7192 58394001401 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2008-07-10 2012-05-25 1 1 UNIT EA
J7192 58394001501 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 2000 (+/-) 2008-07-10 2012-05-25 1 1 UNIT EA
J7192 58394001603 XYNTHA ANTIHEMOPH.FVIII PLAS/ALB FREE 3000 (+/-) 2010-12-30 2012-05-25 1 1 UNIT EA
J7192 58394002203 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2012-01-19 2012-05-25 1 1 UNIT EA
J7192 58394002303 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2012-01-19 2012-05-25 1 1 UNIT EA
J7192 58394002403 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2011-11-09 2012-05-25 1 1 UNIT EA
21
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ7192 58394002503 XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE 2000 (+/-) 2011-11-09 2012-05-25 1 1 UNIT EA
J7192 00053813001 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2007-07-01 2012-12-15 1 1 UNIT EA
J7192 00053813005 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2007-07-13 2012-12-19 1 1 UNIT EA
J7192 00053813002 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2007-07-01 2013-02-17 1 1 UNIT EA
J7192 00053813004 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2007-07-01 2013-02-24 1 1 UNIT EA
J7192 00944283501 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2010-10-05 2013-03-08 1 1 UNIT EA
J7192 00944283510 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2010-10-05 2013-03-08 1 1 UNIT EA
J7192 00944283110 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2007-10-05 2013-11-02 1 1 UNIT EA
J7192 00944283210 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2007-10-05 2014-04-26 1 1 UNIT EA
J7192 00944283310 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2007-10-05 2014-04-26 1 1 UNIT EA
J7192 00944283401 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 1500 (+/-) 2010-10-05 2014-06-02 1 1 UNIT EA
J7192 00944283410 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 1500 (+/-) 2010-10-05 2014-06-02 1 1 UNIT EA
J7192 00026378220 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2008-07-01 2014-12-31 1 1 UNIT EA
J7192 00026378330 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2008-07-01 2014-12-31 1 1 UNIT EA
J7192 00026378550 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2008-07-01 2014-12-31 1 1 UNIT EA
J7192 00026378660 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2007-07-02 2014-12-31 1 1 UNIT EA
J7192 00026378770 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 3000 (+/-) 2009-07-31 2014-12-31 1 1 UNIT EA
J7192 00026378225 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2013-07-09 2299-12-31 1 1 UNIT EA
J7192 00026378335 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2013-07-09 2299-12-31 1 1 UNIT EA
J7192 00026378555 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2013-07-09 2299-12-31 1 1 UNIT EA
J7192 00026378665 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2013-07-09 2299-12-31 1 1 UNIT EA
J7192 00026378775 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 3000 (+/-) 2013-07-09 2299-12-31 1 1 UNIT EA
J7192 00026379220 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2008-07-01 2299-12-31 1 1 UNIT EA
J7192 00026379330 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2008-07-01 2299-12-31 1 1 UNIT EA
J7192 00026379550 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2008-07-01 2299-12-31 1 1 UNIT EA
J7192 00026379660 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2007-07-02 2299-12-31 1 1 UNIT EA
J7192 00026379770 KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 3000 (+/-) 2009-07-31 2299-12-31 1 1 UNIT EA
J7192 00053813102 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2009-12-15 2299-12-31 1 1 UNIT EA
J7192 00053813202 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2009-12-15 2299-12-31 1 1 UNIT EA
J7192 00053813302 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2009-12-15 2299-12-31 1 1 UNIT EA
J7192 00053813402 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2009-12-15 2299-12-31 1 1 UNIT EA
J7192 00053813502 HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 3000 (+/-) 2009-09-10 2299-12-31 1 1 UNIT EA
J7192 00944284110 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) 2011-01-24 2299-12-31 1 1 UNIT EA
J7192 00944284210 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) 2011-01-24 2299-12-31 1 1 UNIT EA
J7192 00944284310 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) 2011-01-24 2299-12-31 1 1 UNIT EA
J7192 00944284410 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 1500 (+/-) 2011-01-24 2299-12-31 1 1 UNIT EA
J7192 00944284510 RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) 2011-01-24 2299-12-31 1 1 UNIT EA
J7192 00944292102 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2012-02-21 2299-12-31 1 1 UNIT EA
J7192 00944292202 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2012-02-21 2299-12-31 1 1 UNIT EA
J7192 00944292302 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2012-02-21 2299-12-31 1 1 UNIT EA
J7192 00944292402 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 1500 (+/-) 2012-02-21 2299-12-31 1 1 UNIT EA
J7192 00944294110 ADVATE L ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2007-07-01 2299-12-31 1 1 UNIT EA
J7192 00944294210 ADVATE M ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2007-07-01 2299-12-31 1 1 UNIT EA
J7192 00944294310 ADVATE H ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2007-07-01 2299-12-31 1 1 UNIT EA
J7192 00944294410 ADVATE SH ANTIHEMOPH.FVIII PLAS/ALB FREE 1500 (+/-) 2007-07-01 2299-12-31 1 1 UNIT EA
J7192 00944294510 ADVATE UH ANTIHEMOPH.FVIII PLAS/ALB FREE 2000 (+/-) 2007-07-01 2299-12-31 1 1 UNIT EA
J7192 00944294610 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 3000 (+/-) 2007-07-05 2299-12-31 1 1 UNIT EA
J7192 00944294810 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 4000 (+/-) 2012-07-16 2299-12-31 1 1 UNIT EA
J7192 00944296010 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2012-07-16 2299-12-31 1 1 UNIT EA
J7192 00944296110 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2012-07-16 2299-12-31 1 1 UNIT EA
J7192 00944296210 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2012-07-16 2299-12-31 1 1 UNIT EA
J7192 00944296310 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 1500 (+/-) 2012-07-16 2299-12-31 1 1 UNIT EA
J7192 00944296410 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 2000 (+/-) 2012-07-16 2299-12-31 1 1 UNIT EA
J7192 00944296510 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 3000 (+/-) 2012-07-16 2299-12-31 1 1 UNIT EA
J7192 00944304510 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 2000 (+/-) 2014-05-15 2299-12-31 1 1 UNIT EA
J7192 00944304610 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 3000 (+/-) 2014-05-15 2299-12-31 1 1 UNIT EA
J7192 00944304710 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 4000 (+/-) 2014-05-15 2299-12-31 1 1 UNIT EA
J7192 00944305102 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 250 (+/-) 2014-05-15 2299-12-31 1 1 UNIT EA
J7192 00944305202 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 500 (+/-) 2014-05-15 2299-12-31 1 1 UNIT EA
22
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ7192 00944305302 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 1000 (+/-) 2014-05-15 2299-12-31 1 1 UNIT EA
J7192 00944305402 ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE 1500 (+/-) 2014-05-15 2299-12-31 1 1 UNIT EA
J7193 00053766801 MONONINE FACTOR IX 250 (+/-) 2007-07-01 2007-11-17 1 1 UNIT EA
J7193 00053766802 MONONINE FACTOR IX 500 (+/-) 2007-07-01 2009-10-18 1 1 UNIT EA
J7193 68516360004 ALPHANINE SD FACTOR IX 500 (+/-) 2009-05-01 2012-05-14 1 1 UNIT EA
J7193 68516360006 ALPHANINE SD FACTOR IX 1500 (+/-) 2009-05-01 2012-09-21 1 1 UNIT EA
J7193 68516360005 ALPHANINE SD FACTOR IX 1000 (+/-) 2009-05-01 2012-10-18 1 1 UNIT EA
J7193 68516360002 ALPHANINE SD FACTOR IX 812 (+/-)U 2007-07-01 2013-03-19 1 1 UNIT EA
J7193 00053766804 MONONINE FACTOR IX 1000 (+/-) 2007-07-01 2014-01-07 1 1 UNIT EA
J7193 00053623302 MONONINE FACTOR IX 1000 (+/-) 2011-05-02 2299-12-31 1 1 UNIT EA
J7193 68516360102 ALPHANINE SD FACTOR IX 500 (+/-) 2010-04-22 2299-12-31 1 1 UNIT EA
J7193 68516360202 ALPHANINE SD FACTOR IX 1000 (+/-) 2010-04-22 2299-12-31 1 1 UNIT EA
J7193 68516360302 ALPHANINE SD FACTOR IX 1500 (+/-) 2010-04-22 2299-12-31 1 1 UNIT EA
J7193 68516360402 ALPHANINE SD FACTOR IX 500 (+/-) 2014-01-07 2299-12-31 1 1 UNIT EA
J7193 68516360502 ALPHANINE SD FACTOR IX 1000 (+/-) 2014-01-07 2299-12-31 1 1 UNIT EA
J7193 68516360602 ALPHANINE SD FACTOR IX 1500 (+/-) 2014-01-07 2299-12-31 1 1 UNIT EA
J7194 00944058101 PROPLEX T FACTOR IX COMPLEX HUMAN 750 (+/-)U 2007-07-01 2007-12-31 1 1 UNIT EA
J7194 68516320002 PROFILNINE SD FACTOR IX COMPLEX HUMAN 500 (+/-) 2007-07-01 2011-12-09 1 1 UNIT EA
J7194 68516320005 PROFILNINE SD FACTOR IX COMPLEX HUMAN 1500 (+/-) 2009-05-01 2012-08-18 1 1 UNIT EA
J7194 68516320004 PROFILNINE SD FACTOR IX COMPLEX HUMAN 1000 (+/-) 2009-05-01 2012-10-31 1 1 UNIT EA
J7194 68516320003 PROFILNINE SD FACTOR IX COMPLEX HUMAN 1200 (+/-) 2007-07-01 2013-07-24 1 1 UNIT EA
J7194 64193024402 BEBULIN VH IMMUNO FACTOR IX COMPLEX HUMAN 700 (+/-)U 2007-07-01 2013-09-30 1 1 UNIT EA
J7194 64193044502 BEBULIN FACTOR IX COMPLEX HUMAN 700 (+/-)U 2011-05-20 2299-12-31 1 1 UNIT EA
J7194 68516320101 PROFILNINE SD FACTOR IX COMPLEX HUMAN 500 (+/-) 2010-04-22 2299-12-31 1 1 UNIT EA
J7194 68516320202 PROFILNINE SD FACTOR IX COMPLEX HUMAN 1000 (+/-) 2010-04-22 2299-12-31 1 1 UNIT EA
J7194 68516320302 PROFILNINE SD FACTOR IX COMPLEX HUMAN 1500 (+/-) 2010-04-22 2299-12-31 1 1 UNIT EA
J7194 68516320401 PROFILNINE SD FACTOR IX COMPLEX HUMAN 500 (+/-) 2014-01-03 2299-12-31 1 1 UNIT EA
J7194 68516320502 PROFILNINE SD FACTOR IX COMPLEX HUMAN 1000 (+/-) 2014-01-06 2299-12-31 1 1 UNIT EA
J7194 68516320602 PROFILNINE SD FACTOR IX COMPLEX HUMAN 1500 (+/-) 2014-01-06 2299-12-31 1 1 UNIT EA
J7196 67386052151 ATRYN ANTITHROMBIN III, HUMAN RECOMB 1750 UNIT 2012-01-01 2012-11-27 35 50 UNITS EA
J7197 67386052151 ATRYN ANTITHROMBIN III, HUMAN RECOMB 1750 UNIT 2012-11-28 2013-06-30 1 1 UNIT EA
J7198 64193022204 FEIBA VH IMMUNO ANTI-INHIBITOR COAGULANT COMP. 651-1200 U 2007-07-01 2012-03-31 1 1 UNIT EA
J7198 64193022203 FEIBA VH IMMUNO ANTI-INHIBITOR COAGULANT COMP. 400-650 U 2007-07-01 2012-06-30 1 1 UNIT EA
J7198 64193022205 FEIBA VH IMMUNO ANTI-INHIBITOR COAGULANT COMP. 1750-3250 2007-07-01 2012-09-30 1 1 UNIT EA
J7198 64193022402 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. 651-1200 U 2010-04-28 2013-09-30 1 1 UNIT EA
J7198 64193022302 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. 400-650 U 2010-04-28 2299-12-31 1 1 UNIT EA
J7198 64193022502 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. 1750-3250 2010-04-28 2299-12-31 1 1 UNIT EA
J7198 64193042302 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. 400-650 U 2013-04-10 2299-12-31 1 1 UNIT EA
J7198 64193042402 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. 651-1200 U 2013-04-10 2299-12-31 1 1 UNIT EA
J7198 64193042502 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. 1750-3250 2013-04-10 2299-12-31 1 1 UNIT EA
J7297 52544003554 LILETTA LEVONORGESTREL 18.6MCG/24 2016-01-01 2299-12-31 1 52 MG EA
J7298 50419042101 MIRENA LEVONORGESTREL 20MCG/24HR 2016-01-01 2299-12-31 1 52 MG EA
J7298 50419042301 MIRENA LEVONORGESTREL 20MCG/24HR 2016-01-01 2299-12-31 1 52 MG EA
J7301 50419042201 SKYLA LEVONORGESTREL 14MCG/24HR 2014-01-01 2299-12-31 EA 13.5 MG EA
J7302 50419042101 MIRENA LEVONORGESTREL 20MCG/24HR 2014-01-01 2015-12-31 EA 52 MG EA
J7302 50419042301 MIRENA LEVONORGESTREL 20MCG/24HR 2014-08-11 2015-12-31 EA 52 MG EA
J7302 52544003554 LILETTA LEVONORGESTREL 18.6MCG/24 2015-03-30 2015-12-31 EA 52 MG EA
J7312 00023334807 OZURDEX DEXAMETHASONE 0.7MG 2012-01-01 2299-12-31 7 0.1 MG EA
J7316 24856000100 JETREA OCRIPLASMIN/PF 2.5 MG/ML 2014-01-01 2299-12-31 20 0.125 MG ML
J7322 21695031303 SYNVISC HYLAN G-F 20 16MG/2ML 2008-01-01 2009-12-31 8 1 MG ML
J7322 35356003401 SYNVISC HYLAN G-F 20 16MG/2ML 2008-01-01 2009-12-31 8 1 MG ML
J7322 54868421900 SYNVISC HYLAN G-F 20 16MG/2ML 2008-01-01 2009-12-31 8 1 MG ML
J7322 58468009001 SYNVISC HYLAN G-F 20 16MG/2ML 2008-01-01 2009-12-31 8 1 MG ML
J7322 58468009003 SYNVISC-ONE HYLAN G-F 20 48 MG/6 ML 2008-01-01 2009-12-31 8 1 MG ML
J7322 66267092103 SYNVISC HYLAN G-F 20 16MG/2ML 2008-01-01 2009-12-31 8 1 MG ML
J7322 68115053503 SYNVISC HYLAN G-F 20 16MG/2ML 2008-01-01 2010-04-01 8 1 MG ML
J7322 35356003403 SYNVISC HYLAN G-F 20 16MG/2ML 2008-01-01 2010-07-02 8 1 MG ML
J7325 21695031303 SYNVISC HYLAN G-F 20 30MG/2ML 2010-01-01 2010-07-01 15 1 MG ML
J7325 35356003401 SYNVISC HYLAN G-F 20 16MG/2ML 2010-01-01 2011-02-10 8 1 MG ML
23
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ7325 54868421900 SYNVISC HYLAN G-F 20 16MG/2ML 2010-01-01 2011-02-10 8 1 MG ML
J7325 66267092103 SYNVISC HYLAN G-F 20 16MG/2ML 2010-01-01 2011-02-10 8 1 MG ML
J7325 58468009001 SYNVISC HYLAN G-F 20 16MG/2ML 2010-01-01 2299-12-31 8 1 MG ML
J7325 58468009003 SYNVISC-ONE HYLAN G-F 20 48 MG/6 ML 2010-01-01 2299-12-31 8 1 MG ML
J7327 59676082001 MONOVISC HYALURONATE SODIUM, STABILIZED 88 MG/4ML 2015-01-01 2299-12-31 22 EA ML
J7335 49685092801 QUTENZA CAPSAICIN/SKIN CLEANSER 8% 2012-08-25 2015-01-01 1 1PATCH EA
J7335 49685092802 QUTENZA CAPSAICIN/SKIN CLEANSER 8% 2012-08-25 2015-01-01 1 1PATCH EA
J7505 59676010101 ORTHOCLONE OKT-3 MUROMONAB-CD3 1 MG/ML 2007-07-01 2012-07-31 0.2 5 MG ML
J7511 58468008001 THYMOGLOBULIN LYMPHOCYTE IMMU GLOB.,RABBIT 25 MG 2007-07-01 2299-12-31 1 25 MG EA
J7513 00004050109 ZENAPAX DACLIZUMAB 5 MG/ML 2007-07-01 2010-12-02 0.2 25 MG ML
J7516 00574086610 CYCLOSPORINE CYCLOSPORINE 250 MG/5ML 2007-07-01 2012-11-22 0.2 250 MG ML
J7516 55390012210 CYCLOSPORINE CYCLOSPORINE 250 MG/5ML 2007-07-01 2015-09-05 0.2 250 MG ML
J7516 00078010901 SANDIMMUNE CYCLOSPORINE 250 MG/5ML 2007-07-01 2299-12-31 0.2 250 MG ML
J7516 00078010961 SANDIMMUNE CYCLOSPORINE 250 MG/5ML 2012-12-06 2299-12-31 0.2 250 MG ML
J7517 00004025901 CELLCEPT MYCOPHENOLATE MOFETIL 250 MG 2007-07-01 2011-03-31 1 250 MG EA
J7517 00004025905 CELLCEPT MYCOPHENOLATE MOFETIL 250 MG 2007-07-01 2011-03-31 1 250 MG EA
J7517 00004025943 CELLCEPT MYCOPHENOLATE MOFETIL 250 MG 2007-07-01 2011-03-31 1 250 MG EA
J7517 00004026001 CELLCEPT MYCOPHENOLATE MOFETIL 500 MG 2007-07-01 2011-03-31 2 250 MG EA
J7517 00004026043 CELLCEPT MYCOPHENOLATE MOFETIL 500 MG 2007-07-01 2011-03-31 2 250 MG EA
J7517 00004026129 CELLCEPT MYCOPHENOLATE MOFETIL 200 MG/ML 2007-07-01 2011-03-31 0.8 250 MG EA
J7517 00004029809 CELLCEPT MYCOPHENOLATE MOFETIL 500 MG 2010-04-29 2011-03-31 2 250 MG EA
J7517 00093747705 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL 500 MG 2009-05-05 2011-03-31 2 250 MG EA
J7525 00469301601 PROGRAF TACROLIMUS ANHYDROUS 5 MG/ML 2007-07-01 2299-12-31 1 5 MG ML
J9000 47335004940 DOXORUBICIN HCL LIPOSOME DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML 2014-01-01 2013-12-31 0.2 10 MG ML
J9000 47335005040 DOXORUBICIN HCL LIPOSOME DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML 2014-01-01 2015-09-08 0.2 10 MG ML
J9000 59676096001 DOXIL DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2014-01-01 2013-12-31 0.2 10 MG ML
J9000 59676096002 DOXIL DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2014-01-01 2013-12-31 0.2 10 MG ML
J9002 47335004940 DOXORUBICIN HCL LIPOSOME DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML 2013-03-15 2013-12-31 0.2 10 MG ML
J9002 47335005040 DOXORUBICIN HCL LIPOSOME DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML 2013-03-15 2013-12-31 0.2 10 MG ML
J9002 59676096001 DOXIL DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2013-01-01 2013-12-31 0.2 10 MG ML
J9002 59676096002 DOXIL DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2013-01-01 2013-12-31 0.2 10 MG ML
J9010 58468020001 LEMTRADA ALEMTUZUMAB 12 MG/1.2 ML 2015-01-01 2015-12-31 1 10 MG ML
J9019 57902024901 ERWINAZE ERWINAZE 10,000 UNITS 2013-01-01 2299-12-31 10 1000 UNITS EA
J9019 57902024905 ERWINAZE ERWINAZE 10,000 UNITS 2013-01-01 2299-12-31 10 1000 UNITS EA
J9025 67211010201 VIDAZA AZACITIDINE 100 MG 2009-01-01 2010-05-01 100 1 MG EA
J9025 00781325394 AZACITIDINE AZACITIDINE 100 MG 2013-09-20 2299-12-31 100 1 MG EA
J9025 00781925394 AZACITIDINE AZACITIDINE 100 MG 2013-10-10 2299-12-31 100 1 MG EA
J9025 43598030562 AZACITIDINE AZACITIDINE 100 MG 2013-09-19 2299-12-31 100 1 MG EA
J9025 43598046562 AZACITIDINE AZACITIDINE 100 MG 2015-07-02 2299-12-31 100 1 MG EA
J9025 59572010201 VIDAZA AZACITIDINE 100 MG 2009-05-08 2299-12-31 100 1 MG EA
J9027 58468010001 CLOLAR CLOFARABINE 20 MG/20ML 2007-07-01 2015-12-15 1 1 MG ML
J9027 58468010002 CLOLAR CLOFARABINE 20 MG/20ML 2007-07-01 2015-12-15 1 1 MG ML
J9027 00024586001 CLOLAR CLOFARABINE 20 MG/20ML 2015-02-16 2299-12-31 1 1 MG ML
J9033 63459039008 TREANDA BENDAMUSTINE HCL 25 MG 2009-12-31 2299-12-31 25 1 MG EA
J9033 63459039120 TREANDA BENDAMUSTINE HCL 100 MG 2009-01-01 2299-12-31 100 1 MG EA
J9033 63459039502 TREANDA BENDAMUSTINE HCL 45MG/0.5ML 2014-10-24 2299-12-31 90 1 MG ML
J9033 63459039602 TREANDA BENDAMUSTINE HCL 180 MG/2ML 2014-10-24 2299-12-31 90 1 MG ML
J9035 50242006001 AVASTIN BEVACIZUMAB 100MG/4ML 2011-04-01 2299-12-31 2.5 10 MG ML
J9035 50242006101 AVASTIN BEVACIZUMAB 400MG/16ML 2011-04-01 2299-12-31 2.5 10 MG ML
J9042 51144005001 ADCETRIS BRENTUXIMAB VEDOTIN 50 MG 2013-01-01 2299-12-31 50 1 MG EA
J9043 00024582411 JEVTANA CABAZITAXEL 60MG/1.5ML 2012-01-01 2299-12-31 40 1 MG ML
J9045 00703324811 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2007-02-01 0.2 50 MG ML
J9045 00703324411 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2007-05-04 0.2 50 MG ML
J9045 00015321430 PARAPLATIN CARBOPLATIN 150 MG 2009-01-01 2009-05-14 3 50 MG EA
J9045 15210006712 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-06-20 0.2 50 MG ML
J9045 00409112910 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-07-01 0.2 50 MG ML
J9045 15210006312 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-07-21 0.2 50 MG ML
J9045 15210006612 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-08-26 0.2 50 MG ML
J9045 00409112911 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-10-01 0.2 50 MG ML
24
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ9045 00409112912 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-10-01 0.2 50 MG ML
J9045 15210006112 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-10-02 0.2 50 MG ML
J9045 00703324611 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2009-12-15 0.2 50 MG ML
J9045 00703326401 CARBOPLATIN CARBOPLATIN 50 MG 2009-01-01 2009-12-15 1 50 MG EA
J9045 00703326601 CARBOPLATIN CARBOPLATIN 150 MG 2009-01-01 2009-12-15 3 50 MG EA
J9045 00703327401 CARBOPLATIN CARBOPLATIN 50 MG 2009-01-01 2009-12-23 1 50 MG EA
J9045 00703327601 CARBOPLATIN CARBOPLATIN 150 MG 2009-01-01 2009-12-23 3 50 MG EA
J9045 00703327801 CARBOPLATIN CARBOPLATIN 450 MG 2009-01-01 2009-12-23 9 50 MG EA
J9045 50111096576 CARBOPLATIN CARBOPLATIN 50 MG 2009-01-01 2009-12-23 1 50 MG EA
J9045 50111096676 CARBOPLATIN CARBOPLATIN 150 MG 2009-01-01 2009-12-23 3 50 MG EA
J9045 50111096776 CARBOPLATIN CARBOPLATIN 450 MG 2009-01-01 2010-10-15 9 50 MG EA
J9045 61703036018 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2010-11-20 0.2 50 MG ML
J9045 61703036022 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2010-11-20 0.2 50 MG ML
J9045 61703036050 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2010-11-20 0.2 50 MG ML
J9045 63323016610 CARBOPLATIN CARBOPLATIN 50 MG 2009-01-01 2010-12-11 1 50 MG EA
J9045 63323016800 CARBOPLATIN CARBOPLATIN 450 MG 2009-01-01 2010-12-11 9 50 MG EA
J9045 61703033963 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2011-04-30 0.2 50 MG ML
J9045 55390022001 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2011-10-31 0.2 50 MG ML
J9045 55390022101 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2011-10-31 0.2 50 MG ML
J9045 55390022201 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2011-10-31 0.2 50 MG ML
J9045 55390015001 CARBOPLATIN CARBOPLATIN 50 MG 2009-01-01 2012-05-02 1 50 MG EA
J9045 55390015101 CARBOPLATIN CARBOPLATIN 150 MG 2009-01-01 2012-05-02 3 50 MG EA
J9045 55390015201 CARBOPLATIN CARBOPLATIN 450 MG 2009-01-01 2012-05-02 9 50 MG EA
J9045 55390015301 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-05-02 0.2 50 MG ML
J9045 55390015401 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-05-02 0.2 50 MG ML
J9045 55390015501 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-05-02 0.2 50 MG ML
J9045 55390015601 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-05-02 0.2 50 MG ML
J9045 61703033961 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-07-19 0.2 50 MG ML
J9045 10139006005 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-09-23 0.2 50 MG ML
J9045 10139006015 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-09-23 0.2 50 MG ML
J9045 10139006045 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-09-23 0.2 50 MG ML
J9045 66758004701 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-12-29 0.2 50 MG ML
J9045 66758004702 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-12-29 0.2 50 MG ML
J9045 66758004703 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2012-12-29 0.2 50 MG ML
J9045 00703324911 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 00703423901 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-10-15 2299-12-31 0.2 50 MG ML
J9045 00703424401 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 00703424601 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 00703424801 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 00703424891 CARBOPLATIN CARBOPLATIN 10 MG/ML 2015-05-20 2299-12-31 0.2 50 MG ML
J9045 25021020205 CARBOPLATIN CARBOPLATIN 10 MG/ML 2013-10-25 2299-12-31 0.2 50 MG ML
J9045 25021020215 CARBOPLATIN CARBOPLATIN 10 MG/ML 2013-10-25 2299-12-31 0.2 50 MG ML
J9045 25021020245 CARBOPLATIN CARBOPLATIN 10 MG/ML 2013-10-25 2299-12-31 0.2 50 MG ML
J9045 25021020251 CARBOPLATIN CARBOPLATIN 10 MG/ML 2013-10-25 2299-12-31 0.2 50 MG ML
J9045 47335015040 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-11-17 2299-12-31 0.2 50 MG ML
J9045 47335015140 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-11-17 2299-12-31 0.2 50 MG ML
J9045 47335028440 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-11-17 2299-12-31 0.2 50 MG ML
J9045 47335030040 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-11-17 2299-12-31 0.2 50 MG ML
J9045 61703033918 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 61703033922 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 61703033950 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 61703033956 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 61703033962 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 63323016721 CARBOPLATIN CARBOPLATIN 150 MG 2009-01-01 2299-12-31 3 50 MG EA
J9045 63323017205 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-09-28 2299-12-31 0.2 50 MG ML
J9045 63323017215 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-09-28 2299-12-31 0.2 50 MG ML
J9045 63323017245 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 63323017260 CARBOPLATIN CARBOPLATIN 10 MG/ML 2009-01-01 2299-12-31 0.2 50 MG ML
J9045 66758004704 CARBOPLATIN CARBOPLATIN 10 MG/ML 2010-03-29 2299-12-31 0.2 50 MG ML
25
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ9045 67457049154 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-05-08 2299-12-31 0.2 50 MG ML
J9045 67457049215 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-05-08 2299-12-31 0.2 50 MG ML
J9045 67457049346 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-05-08 2299-12-31 0.2 50 MG ML
J9045 67457049461 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-05-08 2299-12-31 0.2 50 MG ML
J9045 67457060820 CARBOPLATIN CARBOPLATIN 10 MG/ML 2014-12-18 2299-12-31 0.2 50 MG ML
J9047 76075010101 KYPROLIS CARFILZOMIB 60 MG 2014-01-01 2299-12-31 60 1 MG EA
J9055 66733094823 ERBITUX CETUXIMAB 100MG/50ML 2009-01-01 2299-12-31 0.2 10 MG ML
J9055 66733095823 ERBITUX CETUXIMAB 200MG/0.1L 2009-01-01 2299-12-31 0.2 10 MG ML
J9120 67386081155 COSMEGEN DACTINOMYCIN 0.5 MG 2009-01-01 2015-04-30 1 0.5 MG EA
J9120 55390033701 DACTINOMYCIN DACTINOMYCIN 0.5 MG 2010-07-09 2015-09-05 1 0.5 MG EA
J9120 55292081155 COSMEGEN DACTINOMYCIN 0.5 MG 2013-10-22 2299-12-31 1 0.5 MG EA
J9155 55566830101 FIRMAGON DEGARELIX ACETATE 80 MG 2010-01-01 2299-12-31 80 1 MG EA
J9155 55566830102 FIRMAGON DEGARELIX ACETATE 80 MG 10/22/2012 2299-12-31 80 1 MG EA
J9155 55566830301 FIRMAGON DEGARELIX ACETATE 80 MG 2013-08-01 2299-12-31 80 1 MG EA
J9155 55566840101 FIRMAGON DEGARELIX ACETATE 120 MG X 2 2010-01-01 2299-12-31 120 1 MG EA
J9155 55566840102 FIRMAGON DEGARELIX ACETATE 120 MG 10/22/2012 2299-12-31 120 1 MG EA
J9155 55566840301 FIRMAGON DEGARELIX ACETATE 120 MG 2013-08-01 2299-12-31 120 1 MG EA
J9170 00075800120 TAXOTERE DOCETAXEL FNL 20MG/2 2009-01-01 2009-12-31 0.5 20 MG ML
J9171 60505603500 DOCETAXEL DOCETAXEL FNL 20MG/2 2012-09-18 2013-04-29 10 1 MG ML
J9171 60505603700 DOCETAXEL DOCETAXEL FNL 80MG/8 2012-09-18 2013-04-29 10 1 MG ML
J9171 00075800120 TAXOTERE DOCETAXEL FNL 20MG/2 2010-01-01 2013-05-03 10 1 MG ML
J9171 00075800180 TAXOTERE DOCETAXEL FNL 80MG/8 2010-01-01 2014-06-30 10 1 MG ML
J9171 60505603506 DOCETAXEL DOCETAXEL FNL 20MG/2 2012-09-18 2015-01-31 10 1 MG ML
J9171 60505603706 DOCETAXEL DOCETAXEL FNL 80MG/8 2012-09-18 2015-01-31 10 1 MG ML
J9171 00069914122 DOCETAXEL DOCETAXEL 20 MG/2 ML 2014-06-30 2299-12-31 10 1 MG ML
J9171 00069914222 DOCETAXEL DOCETAXEL 80 MG/8 ML 2014-06-30 2299-12-31 10 1 MG ML
J9171 00069914411 DOCETAXEL DOCETAXEL 200MG/20ML 2015-02-23 2299-12-31 10 1 MG ML
J9171 00075800301 TAXOTERE DOCETAXEL 20MG/ML(1) 2010-10-11 2299-12-31 20 1 MG ML
J9171 00075800404 TAXOTERE DOCETAXEL 80 MG/4 ML 2010-10-11 2299-12-31 20 1 MG ML
J9171 00409020102 DOCETAXEL DOCETAXEL 20 MG/2 ML 2011-03-17 2299-12-31 10 1 MG ML
J9171 00409020110 DOCETAXEL DOCETAXEL 80 MG/8 ML 2011-03-17 2299-12-31 10 1 MG ML
J9171 00409020120 DOCETAXEL DOCETAXEL 160MG/16ML 2011-03-17 2299-12-31 10 1 MG ML
J9171 00409020125 DOCETAXEL DOCETAXEL 20 MG/2 ML 2013-09-12 2299-12-31 10 1 MG ML
J9171 00409020126 DOCETAXEL DOCETAXEL 80 MG/8 ML 2013-09-09 2299-12-31 10 1 MG ML
J9171 00409020127 DOCETAXEL DOCETAXEL 160MG/16ML 2013-10-08 2299-12-31 10 1 MG ML
J9171 00955102001 DOCETAXEL DOCETAXEL 20MG/ML(1) 2011-03-14 2299-12-31 20 1 MG ML
J9171 00955102104 DOCETAXEL DOCETAXEL 80 MG/4 ML 2011-03-14 2299-12-31 20 1 MG ML
J9171 16729012049 DOCETAXEL DOCETAXEL FNL 20MG/2 2011-07-11 2299-12-31 10 1 MG ML
J9171 16729022850 DOCETAXEL DOCETAXEL FNL 80MG/8 2011-07-11 2299-12-31 10 1 MG ML
J9171 16729023163 DOCETAXEL DOCETAXEL 20MG/ML(1) 2012-07-01 2299-12-31 20 1 MG ML
J9171 16729023164 DOCETAXEL DOCETAXEL 80 MG/4 ML 2012-07-01 2299-12-31 20 1 MG ML
J9171 16729023165 DOCETAXEL DOCETAXEL 160 MG/8ML 2012-07-01 2299-12-31 20 1 MG ML
J9171 16729026763 DOCETAXEL DOCETAXEL 20MG/ML(1) 2013-05-30 2299-12-31 10 1 MG ML
J9171 16729026764 DOCETAXEL DOCETAXEL 80 MG/4 ML 2013-05-30 2299-12-31 10 1 MG ML
J9171 16729026765 DOCETAXEL DOCETAXEL 160 MG/8ML 2013-05-30 2299-12-31 10 1 MG ML
J9171 25021022201 DOCETAXEL DOCETAXEL 20MG/ML(1) 2013-07-18 2299-12-31 10 1 MG ML
J9171 25021022204 DOCETAXEL DOCETAXEL 80 MG/4 ML 2013-07-18 2299-12-31 10 1 MG ML
J9171 25021022207 DOCETAXEL DOCETAXEL 140 MG/7ML 2013-07-19 2299-12-31 20 1 MG ML
J9171 43598025811 DOCETAXEL DOCETAXEL 20MG/ML(1) 2013-07-22 2299-12-31 20 1 MG ML
J9171 43598025940 DOCETAXEL DOCETAXEL 80 MG/4 ML 2013-07-22 2299-12-31 20 1 MG ML
J9171 45963073452 DOCETAXEL DOCETAXEL 80 MG/4 ML 2013-07-22 2299-12-31 20 1 MG ML
J9171 45963073454 DOCETAXEL DOCETAXEL 20MG/ML(1) 2013-07-22 2299-12-31 20 1 MG ML
J9171 45963073474 DOCETAXEL DOCETAXEL 140 MG/7ML 2015-01-13 2299-12-31 20 1 MG ML
J9171 47335028541 DOCEFREZ DOCETAXEL 20 MG 2011-05-12 2299-12-31 20 1 MG EA
J9171 47335028641 DOCEFREZ DOCETAXEL 80 MG 2011-05-12 2299-12-31 80 1 MG EA
J9171 63739093211 DOCETAXEL DOCETAXEL 20MG/ML(1) 2013-07-22 2299-12-31 20 1 MG ML
J9171 63739097117 DOCETAXEL DOCETAXEL 80 MG/4 ML 2013-07-22 2299-12-31 20 1 MG ML
J9171 66758005001 DOCETAXEL DOCETAXEL 20 MG/2 ML 2011-11-08 2299-12-31 10 1 MG ML
J9171 66758005002 DOCETAXEL DOCETAXEL 80 MG/8 ML 2011-11-08 2299-12-31 10 1 MG ML
26
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ9171 66758005003 DOCETAXEL DOCETAXEL 160MG/16ML 2011-11-08 2299-12-31 10 1 MG ML
J9171 66758095002 DOCETAXEL DOCETAXEL 20 MG/2 ML 2015-07-22 2299-12-31 10 1 MG ML
J9171 66758095003 DOCETAXEL DOCETAXEL 80 MG/8 ML 2015-07-22 2299-12-31 10 1 MG ML
J9171 66758095004 DOCETAXEL DOCETAXEL 160MG/16ML 2015-07-22 2299-12-31 10 1 MG ML
J9179 62856038901 HALAVEN ERIBULIN MESYLATE 1MG/2ML 2012-01-01 2299-12-31 5 0.1 MG ML
J9207 00015191012 IXEMPRA IXABEPILONE 15 MG 2009-01-01 2299-12-31 15 1 MG EA
J9207 00015191113 IXEMPRA IXABEPILONE 45 MG 2009-01-01 2299-12-31 45 1 MG EA
J9217 00185740085 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2011-09-24 2011-12-31 0.133 7.5 MG EA
J9217 00703401418 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2011-09-24 2011-12-31 0.133 7.5 MG EA
J9217 41616093640 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2011-09-24 2011-12-31 0.133 7.5 MG EA
J9217 00024022205 ELIGARD LEUPROLIDE ACETATE 22.5 MG 2011-09-24 2015-10-30 3 7.5 MG EA
J9217 00024060545 ELIGARD LEUPROLIDE ACETATE 45 MG 2011-09-24 2015-10-30 6 7.5 MG EA
J9217 00024061030 ELIGARD LEUPROLIDE ACETATE 30 MG 2011-09-24 2015-10-30 4 7.5 MG EA
J9217 00024079375 ELIGARD LEUPROLIDE ACETATE 7.5 MG 2011-09-24 2015-10-30 1 7.5 MG EA
J9217 62935030129 ELIGARD LEUPROLIDE ACETATE 30 MG 2014-10-09 2016-05-07 4 7.5 MG EA
J9217 62935030230 ELIGARD LEUPROLIDE ACETATE 30 MG 2014-10-02 2016-05-07 4 7.5 MG EA
J9217 62935045144 ELIGARD LEUPROLIDE ACETATE 45 MG 2014-10-09 2016-05-07 6 7.5 MG EA
J9217 62935045245 ELIGARD LEUPROLIDE ACETATE 45 MG 2014-09-02 2016-05-07 6 7.5 MG EA
J9217 62935075174 ELIGARD LEUPROLIDE ACETATE 7.5 MG 2014-10-09 2016-05-07 1 7.5 MG EA
J9217 62935075275 ELIGARD LEUPROLIDE ACETATE 7.5 MG 2014-09-25 2016-05-07 1 7.5 MG EA
J9217 00074347303 LUPRON DEPOT LEUPROLIDE ACETATE 45 MG 2011-06-18 2299-12-31 6 7.5 MG EA
J9217 47335093640 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1 MG/0.2ML 2015-03-06 2299-12-31 0.133 7.5 MG EA
J9217 62935022004 ELIGARD LEUPROLIDE ACETATE 22.5 MG 2014-10-09 2299-12-31 3 7.5 MG EA
J9217 62935022104 ELIGARD LEUPROLIDE ACETATE 22.5 MG 2015-05-11 2299-12-31 3 7.5 MG EA
J9217 62935022205 ELIGARD LEUPROLIDE ACETATE 22.5 MG 2014-08-27 2299-12-31 3 7.5 MG EA
J9217 62935022305 ELIGARD LEUPROLIDE ACETATE 22.5 MG 2015-05-07 2299-12-31 3 7.5 MG EA
J9218 00185740085 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2012-01-01 2012-11-01 1 1 MG EA
J9218 41616093640 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2012-01-01 2016-03-02 1 1 MG EA
J9218 00703401418 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2012-01-01 2299-12-31 1 1 MG EA
J9218 00781400332 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML 2013-01-28 2299-12-31 1 1 MG EA
J9225 55592050001 VANTAS HISTRELIN AC 50 MG 2009-01-01 2008-07-24 1 50 MG EA
J9225 67979000201 SUPPRELIN LA HISTRELIN AC 50 MG 2009-01-01 2012-05-25 1 50 MG EA
J9225 67979050001 VANTAS HISTRELIN AC 50 MG 2009-01-01 2299-12-31 1 50 MG EA
J9226 67979000201 SUPPRELIN LA HISTRELIN AC 50 MG 2012-05-26 2299-12-31 1 50 MG EA
J9228 00003232711 YERVOY IPILIMUMAB 50MG/10ML 2012-01-01 2299-12-31 5 1 MG ML
J9228 00003232822 YERVOY IPILIMUMAB 200MG/40ML 2012-01-01 2299-12-31 5 1 MG ML
J9261 00007440101 ARRANON NELARABINE 250MG/50ML 2009-01-01 2299-12-31 0.1 50 MG ML
J9261 00007440106 ARRANON NELARABINE 250MG/50ML 2009-01-01 2299-12-31 0.1 50 MG ML
J9263 66758005301 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2009-09-14 2011-02-28 10 0.5 MG ML
J9263 66758005302 OXALIPLATIN OXALIPLATIN 100MG/20ML 2009-09-14 2011-02-28 10 0.5 MG ML
J9263 41616017640 OXALIPLATIN OXALIPLATIN 50 MG 2010-02-02 2013-05-31 10 0.5 MG ML
J9263 41616017840 OXALIPLATIN OXALIPLATIN 100 MG 2010-01-11 2013-05-31 10 0.5 MG ML
J9263 00069006701 OXALIPLATIN OXALIPLATIN 50 MG 2013-05-17 2014-01-01 100 0.5 MG EA
J9263 00069007001 OXALIPLATIN OXALIPLATIN 100MG/20ML 2012-08-08 2014-01-01 10 0.5 MG ML
J9263 00069007401 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2012-08-08 2014-01-01 10 0.5 MG ML
J9263 00069101001 OXALIPLATIN OXALIPLATIN 100 MG 2013-05-17 2014-01-01 200 0.5 MG EA
J9263 00024059240 ELOXATIN OXALIPLATIN 200MG/40ML 2009-01-01 2014-06-25 10 0.5 MG ML
J9263 63323065010 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2009-10-10 2016-07-30 10 0.5 MG ML
J9263 00024059010 ELOXATIN OXALIPLATIN 50 MG/10ML 2009-01-01 2299-12-31 10 0.5 MG ML
J9263 00024059120 ELOXATIN OXALIPLATIN 100MG/20ML 2009-01-01 2299-12-31 10 0.5 MG ML
J9263 00703398501 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2009-08-11 2299-12-31 10 0.5 MG ML
J9263 00703398601 OXALIPLATIN OXALIPLATIN 100MG/20ML 2009-08-11 2299-12-31 10 0.5 MG ML
J9263 00781331570 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2015-04-14 2299-12-31 10 0.5 MG ML
J9263 00781331780 OXALIPLATIN OXALIPLATIN 100MG/20ML 2015-04-14 2299-12-31 10 0.5 MG ML
J9263 00955172510 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2014-07-28 2299-12-31 10 0.5 MG ML
J9263 00955172720 OXALIPLATIN OXALIPLATIN 100MG/20ML 2014-07-28 2299-12-31 10 0.5 MG ML
J9263 25021021120 OXALIPLATIN OXALIPLATIN 50 MG 2012-08-09 2299-12-31 100 0.5 MG EA
J9263 25021021250 OXALIPLATIN OXALIPLATIN 100 MG 2012-08-09 2299-12-31 200 0.5 MG EA
J9263 25021023310 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2014-09-03 2299-12-31 10 0.5 MG ML
27
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ9263 25021023320 OXALIPLATIN OXALIPLATIN 100MG/20ML 2014-09-03 2299-12-31 10 0.5 MG ML
J9263 45963061153 OXALIPLATIN OXALIPLATIN 50 MG 2015-01-13 2299-12-31 100 0.5 MG EA
J9263 45963061159 OXALIPLATIN OXALIPLATIN 100 MG 2015-01-13 2299-12-31 200 0.5 MG EA
J9263 47335004640 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2014-06-13 2299-12-31 10 0.5 MG ML
J9263 47335004740 OXALIPLATIN OXALIPLATIN 100MG/20ML 2014-06-13 2299-12-31 10 0.5 MG ML
J9263 47335017640 OXALIPLATIN OXALIPLATIN 50 MG 2012-08-09 2299-12-31 100 0.5 MG EA
J9263 47335017840 OXALIPLATIN OXALIPLATIN 100 MG 2012-08-09 2299-12-31 200 0.5 MG EA
J9263 61703036318 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2009-08-11 2299-12-31 10 0.5 MG ML
J9263 61703036322 OXALIPLATIN OXALIPLATIN 100MG/20ML 2009-08-13 2299-12-31 10 0.5 MG ML
J9263 63323017530 OXALIPLATIN OXALIPLATIN 50 MG 2010-01-06 2299-12-31 10 0.5 MG ML
J9263 63323017650 OXALIPLATIN OXALIPLATIN 100 MG 2010-01-06 2299-12-31 10 0.5 MG ML
J9263 63323021110 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2014-08-25 2299-12-31 10 0.5 MG ML
J9263 63323021220 OXALIPLATIN OXALIPLATIN 100MG/20ML 2014-08-25 2299-12-31 10 0.5 MG ML
J9263 63323065017 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2012-09-07 2299-12-31 10 0.5 MG ML
J9263 63323065020 OXALIPLATIN OXALIPLATIN 100MG/20ML 2009-10-10 2299-12-31 10 0.5 MG ML
J9263 63323065027 OXALIPLATIN OXALIPLATIN 100MG/20ML 2012-09-07 2299-12-31 10 0.5 MG ML
J9263 63323075010 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2015-07-30 2299-12-31 10 0.5 MG ML
J9263 67457044220 OXALIPLATIN OXALIPLATIN 100MG/20ML 2014-05-12 2299-12-31 10 0.5 MG ML
J9263 67457046910 OXALIPLATIN OXALIPLATIN 50 MG/10ML 2014-08-19 2299-12-31 10 0.5 MG ML
J9263 67457047610 OXALIPLATIN OXALIPLATIN 100 MG 2014-09-04 2299-12-31 10 0.5 MG ML
J9264 68817013450 ABRAXANE PACLITAXEL PROTEIN-BOUND 100 MG 2009-01-01 2299-12-31 100 1 MG EA
J9265 00015347530 TAXOL PACLITAXEL 30MG/5ML 2009-11-18 2014-12-31 6 1 MG ML
J9265 00015347630 TAXOL PACLITAXEL 100MG/16.7ML 2009-11-18 2014-12-31 6 1 MG ML
J9265 00015347911 TAXOL PACLITAXEL 300MG/50ML 2009-11-18 2014-12-31 6 1 MG ML
J9267 00015347530 TAXOL PACLITAXEL 30MG/5ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 00015347630 TAXOL PACLITAXEL 100MG/16.7ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 00015347911 TAXOL PACLITAXEL 300MG/50ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 00172375494 ONXOL 30 MG/5 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 00703476401 PACLITAXEL 30 MG/5 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 00703476601 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 00703476701 PACLITAXEL 150 MG/25 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 00703476801 PACLITAXEL 300 MG/50 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 25021021305 PACLITAXEL 30 MG/5 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 25021021317 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 25021021350 PACLITAXEL 300 MG/50 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 44567050501 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 45963061353 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 61703034209 PACLITAXEL 30 MG/5 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 61703034222 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 61703034250 PACLITAXEL 300 MG/50 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 63323076305 PACLITAXEL 30 MG/5 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 63323076306 PACLITAXEL 30 MG/5 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 63323076316 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 63323076317 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 63323076350 PACLITAXEL 300 MG/50 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 63323076352 PACLITAXEL 300 MG/50 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 66758004301 PACLITAXEL 30 MG/5 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 66758004302 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 66758004303 PACLITAXEL 300 MG/50 ML VIAL PACLITAXEL 6MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 67457043451 PACLITAXEL 300 MG/50 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 67457044917 PACLITAXEL 100 MG/16.7 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9267 67457047152 PACLITAXEL 30 MG/5 ML VIAL PACLITAXEL 6 MG/ML 2015-01-01 2299-12-31 6 1 MG ML
J9266 57665000202 ONCASPAR PEGASPARGASE 750/ML 2009-01-01 2012-10-01 0.2 VIAL ML
J9266 54482030101 ONCASPAR PEGASPARGASE 750/ML 2011-10-01 2299-12-31 0.2 VIAL ML
J9299 00003377211 OPDIVO NIVOLUMAB 40MG/4ML 2016-01-01 2299-12-31 10 1 MG ML
J9299 00003377412 OPDIVO NIVOLUMAB 100 MG/10 ML 2016-01-01 2299-12-31 10 1 MG ML
J9301 50242007001 GAZYVA OBINUTUZUMAB 1000 MG/ML 2015-01-01 2299-12-31 100 10 MG ML
J9301 50242007001 GAZYVA OBINUTUZUMAB 1000MG/40ML 2015-01-01 2299-12-31 2.5 10 MG ML
J9302 00173080802 ARZERRA OFATUMUMAB 100MG/5ML 2011-01-01 2012-07-22 2 10 MG ML
28
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsJ9302 00173080805 ARZERRA OFATUMUMAB 100MG/5ML 2011-01-01 2012-07-22 2 10 MG ML
J9302 00173082101 ARZERRA OFATUMUMAB 1000 MG/50 2011-06-20 2299-12-31 2 10 MG ML
J9302 00173082102 ARZERRA OFATUMUMAB 100 MG/5ML 2015-06-03 2299-12-31 2 10 MG ML
J9302 00173082133 ARZERRA OFATUMUMAB 100 MG/5ML 2011-06-20 2299-12-31 2 10 MG ML
J9303 55513095501 VECTIBIX PANITUMUMAB 200MG/10ML 2009-01-01 2011-02-28 2 10 MG ML
J9303 55513095401 VECTIBIX PANITUMUMAB 100 MG/5ML 2009-01-01 2299-12-31 2 10 MG ML
J9303 55513095601 VECTIBIX PANITUMUMAB 400MG/20ML 2009-01-01 2299-12-31 2 10 MG ML
J9306 50242014501 PERJETA PERTUZUMAB 420 MG/14 ML 2014-01-01 2299-12-31 30 1 MG ML
J9307 48818000101 FOLOTYN PRALATREXATE 20MG/ML 2011-01-01 2299-12-31 20 1 MG ML
J9307 48818000102 FOLOTYN PRALATREXATE 40MG/2ML 2011-01-01 2299-12-31 20 1 MG ML
J9308 00002766901 CYRAMZA RAMUCIRUMAB 100 MG/10 ML 2016-01-01 2299-12-31 2 5 MG ML
J9308 00002767801 CYRAMZA RAMUCIRUMAB 500 MG/50 ML 2016-01-01 2299-12-31 2 5 MG ML
J9310 50242005121 RITUXAN RITUXIMAB 10 MG/ML 2009-01-01 2299-12-31 0.1 100 MG ML
J9310 50242005306 RITUXAN RITUXIMAB 10 MG/ML 2009-01-01 2299-12-31 0.1 100 MG ML
J9315 59572098301 ISTODAX ROMIDEPSIN 10 MG 2011-01-01 2299-12-31 10 1 MG EA
J9328 00085138101 TEMODAR TEMOZOLOMIDE 100 MG 2010-01-01 2299-12-31 100 1 MG EA
J9330 00008117901 TORISEL TEMSIROLIMUS FNL 30MG/3 2009-01-01 2299-12-31 25 1 MG ML
J9330 00008117905 TORISEL TEMSIROLIMUS FNL 30MG/3 2009-01-01 2299-12-31 25 1 MG ML
J9351 00069007501 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2012-10-29 2014-01-01 40 0.1 MG EA
J9351 66435041005 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2011-01-01 2014-05-21 40 0.1 MG EA
J9351 00007420101 HYCAMTIN TOPOTECAN HCL 4 MG 2011-01-01 2299-12-31 40 0.1 MG EA
J9351 00409030201 TOPOTECAN HCL TOPOTECAN HCL 4 MG/4 ML 2011-01-01 2299-12-31 40 0.1 MG ML
J9351 00409030225 TOPOTECAN HCL TOPOTECAN HCL 4 MG/4 ML 2013-09-24 2299-12-31 10 0.1 MG ML
J9351 00703471401 TOPOTECAN HCL TOPOTECAN HCL 4 MG/4 ML 2013-05-14 2299-12-31 10 0.1 MG ML
J9351 00703471471 TOPOTECAN HCL TOPOTECAN HCL 4 MG/4 ML 2013-05-14 2299-12-31 10 0.1 MG ML
J9351 16729015131 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2013-07-23 2299-12-31 40 0.1 MG EA
J9351 25021020606 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2011-01-01 2299-12-31 40 0.1 MG EA
J9351 25021020661 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2011-03-22 2299-12-31 40 0.1 MG EA
J9351 25021023604 TOPOTECAN HCL TOPOTECAN HCL 4 MG/4 ML 2014-12-22 2299-12-31 10 0.1 MG ML
J9351 25021082406 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2011-06-15 2299-12-31 40 0.1 MG EA
J9351 45963061556 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2015-01-13 2299-12-31 40 0.1 MG EA
J9351 55390037010 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2011-04-15 2299-12-31 40 0.1 MG EA
J9351 62756002340 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2013-10-21 2299-12-31 40 0.1 MG EA
J9351 63323076210 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2011-01-01 2299-12-31 40 0.1 MG EA
J9351 63323076217 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2011-01-01 2299-12-31 40 0.1 MG EA
J9351 63323076294 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2013-08-01 2299-12-31 40 0.1 MG EA
J9351 67457047404 TOPOTECAN HCL TOPOTECAN HCL 4 MG 2014-09-04 2299-12-31 40 0.1 MG EA
J9354 50242008701 KADCYLA ADO-TRASTUZUMAB EMTANSINE 160 MG 2014-01-01 2299-12-31 160 1 MG EA
J9354 50242008801 KADCYLA ADO-TRASTUZUMAB EMTANSINE 100 MG 2014-01-01 2299-12-31 100 1 MG EA
J9371 20536032201 MARQIBO VINCRISTINE SULFATE LIPOSOMAL FNL 5MG/31 2014-01-01 2299-12-31 5 1 MG EA
J9999 00024582411 JEVTANA CABAZITAXEL 60MG/1.5ML 2010-06-17 2011-12-31 1 1 MG ML
J9999 62856038901 HALAVEN ERIBULIN MESYLATE 1MG/2ML 2010-11-15 2011-12-31 1 1 MG ML
Q0090 50419042201 SKYLA LEVONORGESTREL 14MCG/24HR 2013-07-01 2013-12-31 13.5 13.5 MG EA
Q0138 59338077501 FERAHEME FERUMOXYTOL 510 MG/17 ML 2014-11-25 2299-12-31 30 1 MG ML
Q0138 59338077510 FERAHEME FERUMOXYTOL 510 MG/17 ML 2014-11-25 2299-12-31 30 1 MG ML
Q2043 30237890006 PROVENGE SIPULEUCEL-T/LACTATED RINGERS 50MM/250 2012-04-11 2299-12-31 1 1 UNIT EA
Q2044 49401010101 BENLYSTA BELIMUMAB 120 MG 2011-07-01 2011-12-31 12 10 MG EA
Q2044 49401010201 BENLYSTA BELIMUMAB 400 MG 2011-07-01 2011-12-31 40 10 MG EA
Q2045 63833089151 RIASTAP FIBRINOGEN 900-1300 MG 2012-07-01 2012-12-31 1 1 MG EA
Q2045 63833891501 RIASTAP FIBRINOGEN 900-1300 MG 2012-07-01 2012-12-31 1 1 MG EA
Q2046 00024584001 ZALTRAP AFLIBERCEPT 100 MG/4ML 2012-08-16 2012-12-31 25 1 MG ML
Q2046 00024584101 ZALTRAP AFLIBERCEPT 200 MG/8ML 2012-08-16 2012-12-31 25 1 MG ML
Q2046 61755000502 EYLEA AFLIBERCEPT 2MG/0.05ML 2012-07-01 2012-12-31 40 1 MG ML
Q2047 64764061010 OMONTYS PEGINESATIDE 10MG/ML 2012-07-01 2012-12-31 100 0.1 MG ML
Q2047 64764062020 OMONTYS PEGINESATIDE 20MG/2ML 2012-07-01 2012-12-31 100 0.1 MG ML
Q2048 59676096001 DOXIL DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2012-07-01 2012-12-31 0.2 10 MG ML
Q2048 59676096002 DOXIL DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2012-07-01 2012-12-31 0.2 10 MG ML
Q2049 47335008250 LIPODOX DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2012-07-01 2299-12-31 0.2 10 MG ML
Q2049 47335008350 LIPODOX 50 DOXORUBICIN HCL LIPOSOMAL 2MG/ML 2012-07-01 2299-12-31 0.2 10 MG ML
29
Physician Injectable Drug List
Jcode NDC Brand Name Generic Name StrengthEffective
Begin Date
Effective
End Date
Conversion
FactorJcode Billing Units
NDC
Billing
UnitsQ2050 47335005040 DOXORUBICIN HCL LIPOSOME DOXORUBICIN HCL LIPOSOME 2mg/ML 2015-09-09 2299-12-31 0.2 10 MG ML
Q9970 00517065001 INJECTAFER FERRIC CARBOXYMALTOSE 750 MG/15 ML 2014-11-25 2014-12-31 50 1 MG ML
30