CODING FOR THE NON-CODER HCPCS LEVEL II – HCPCS CODES SANDY SAGE R.N.
NDC HCPCS HCPCS Description NDC Description Date End Date ...
Transcript of NDC HCPCS HCPCS Description NDC Description Date End Date ...
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
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Schedule68152-0103-03 A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN ZEVALIN Y-90 VIAL 9/1/2013 99/99/9999 M0150419-0320-05 A9581 INJECTION, GADOXETATE DISODIUM, 1 ML EOVIST 2.5 MMOL/10 ML VIAL 10/1/2011 99/99/9999 M0100003-2187-10 J0129 ABATACEPT INJECTION ORENCIA 250 MG VIAL 7/1/2015 99/99/9999 M0100002-7140-01 J0130 ABCIXIMAB REOPRO 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100074-3799-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML SYRINGE 7/1/2015 99/99/9999 M0100074-4339-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML PEN 7/1/2015 99/99/9999 M0100074-4339-06 J0135 INJECTION (HUMIRA) HUMIRA CROHN'S STARTER PACK 7/1/2015 99/99/9999 M0100409-4901-18 J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 0.1 MG/ML SYRINGE 1/1/2013 99/99/9999 M0100409-7241-01 J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 1 MG/ML AMPUL 1/1/2013 99/99/9999 M0142023-0122-25 J0171 ADRENALIN EPINEPHRINE INJECT ADRENALIN CL 1 MG/ML VIAL 1/1/2013 9/30/2014 M0149502-0500-02 J0171 ADRENALIN EPINEPHRINE INJECT EPIPEN 2-PAK 0.3 MG AUTO-INJCT 1/1/2013 99/99/9999 M0176329-3316-01 J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 0.1 MG/ML SYRINGE 1/1/2013 99/99/9999 M0158468-0040-01 J0180 AGALSIDASE INJECTION FABRAZYME 35 MG VIAL 7/1/2015 99/99/9999 M0158468-0041-01 J0180 AGALSIDASE INJECTION FABRAZYME 5 MG VIAL 7/1/2015 99/99/9999 M0162756-0581-40 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 3/31/2014 M0162756-0581-42 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 3/31/2014 M0155390-0308-03 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/2010 12/31/2016 M0158178-0017-01 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/2013 M0158178-0017-03 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/2013 M0158468-0150-01 J0220 ALGLUCOSIDASE ALFA INJECTION MYOZYME 50 MG VIAL 7/1/2015 99/99/9999 M0158468-0160-01 J0221 LUMIZYME INJECTION LUMIZYME 50 MG VIAL 1/1/2012 99/99/9999 M0100053-7201-02 J0256 ALPHA 1 PROTEINASE INHIBITOR ZEMAIRA 1,000 MG VIAL 7/1/2015 99/99/9999 M0100944-2884-01 J0257 GLASSIA INJECTION GLASSIA 1 GM/50 ML VIAL 1/1/2012 99/99/9999 M0100009-3169-06 J0270 INJECTION, ALPPROSTADIL PROSTIN VR PEDI 500 MCG/ML AMP 7/1/2015 99/99/9999 M0100009-3701-05 J0270 INJECTION, ALPPROSTADIL CAVERJECT 20 MCG VIAL 7/1/2015 99/99/9999 M0100009-5181-01 J0270 INJECTION, ALPPROSTADIL CAVERJECT IMPULSE 10 MCG KIT 7/1/2015 99/99/9999 M0100009-5182-01 J0270 INJECTION, ALPPROSTADIL CAVERJECT IMPULSE 20 MCG KIT 7/1/2015 99/99/9999 M0100009-7686-04 J0270 INJECTION, ALPPROSTADIL CAVERJECT 40 MCG VIAL 7/1/2015 99/99/9999 M0100703-1501-02 J0270 INJECTION, ALPPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 7/1/2015 99/99/9999 M0100703-9032-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100703-9040-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 1 GRAM/4 ML VIAL 7/1/2015 99/99/9999 M0155390-0226-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 7/1/2015 7/31/2015 M0100409-5921-01 J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 7/1/2015 99/99/9999 M0100409-5922-01 J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 7/1/2015 99/99/9999 M0139822-1055-05 J0285 AMPHOTERICIN B AMPHOTERICIN B 50 MG VIAL 7/1/2015 99/99/9999 M0157665-0101-41 J0287 INJECTION AMPHOTERICIN B LIPID COMPLEX ABELCET 100 MG/20 ML VIAL 7/1/2015 99/99/9999 M0100469-3051-30 J0289 INJECT, AMPHOTERICIN B LIPOSOME AMBISOME 50 MG VIAL 7/1/2015 99/99/9999 M0100781-3400-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 7/1/2015 99/99/9999 M0100781-3402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 7/1/2015 99/99/9999 M0100781-3404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100781-3407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100781-3408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 7/1/2015 99/99/9999 M0100781-3409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100781-3412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 7/1/2015 99/99/9999 M0100781-3413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 7/1/2015 99/99/9999 M0100781-9401-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 7/1/2015 99/99/9999 M0100781-9402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 7/1/2015 99/99/9999 M0100781-9404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100781-9407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100781-9408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 7/1/2015 99/99/9999 M0100781-9409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100781-9412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 7/1/2015 99/99/9999 M0100781-9413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 7/1/2015 99/99/9999 M0163323-0387-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 7/1/2015 99/99/9999 M0163323-0388-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0389-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 7/1/2015 99/99/9999 M0163323-0399-23 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 7/1/2015 99/99/9999 M0100049-0013-83 J0295 AMPICILLIN/SULBACTAM 1.5GM UNASYN 1.5 GM VIAL 7/1/2015 99/99/9999 M0100049-0014-83 J0295 AMPICILLIN/SULBACTAM 1.5GM UNASYN 3 GM VIAL 7/1/2015 99/99/9999 M0100049-0024-28 J0295 AMPICILLIN/SULBACTAM 1.5GM UNASYN 15 GM VIAL 7/1/2015 99/99/9999 M0100409-2687-15 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 15 GM VL 7/1/2015 99/99/9999 M0100409-2689-01 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0100409-2987-03 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULB 3 GM ADD VIAL 7/1/2015 99/99/9999 M0100409-2988-01 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0100409-2998-03 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 3 GM VIAL 7/1/2015 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
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Schedule00781-3032-95 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0100781-3033-95 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 3 GM VIAL 7/1/2015 99/99/9999 M0100781-3034-46 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 15 GM VL 7/1/2015 99/99/9999 M0163323-0368-20 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 1.5 GM VL 7/1/2015 99/99/9999 M0163323-0369-20 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 3 GM VIAL 7/1/2015 99/99/9999 M0163323-0370-62 J0295 AMPICILLIN/SULBACTAM 1.5GM AMPICILLIN-SULBACTAM 15 GM VL 7/1/2015 99/99/9999 M0100409-6629-02 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 200 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100781-3009-95 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T ANECTINE 20 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0614-01 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0614-55 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 7/1/2015 99/99/9999 M0159148-0016-65 J0400 ARIPIPRAZOLE INJECTION ABILIFY 9.7 MG/1.3 ML VIAL 7/1/2015 99/99/9999 M0100069-3150-83 J0456 INJECTION, AZITHROMYCIN ZITHROMAX I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0150111-0794-78 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0398-10 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0398-12 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 7/1/2015 99/99/9999 M0100517-1010-25 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 1 MG/ML VIAL 3/1/2010 99/99/9999 M0100641-6006-10 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 8 MG/20 ML VIAL 8/29/2012 99/99/9999 M0100409-4910-34 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 0.1 MG/ML ABBOJECT 3/1/2010 99/99/9999 M0158281-0560-01 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0560-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0561-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/5 ML KIT 7/1/2015 99/99/9999 M0158281-0563-01 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0563-02 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 7/1/2015 99/99/9999 M0158281-0562-01 J0476 BACLOFEN LIORESAL IT 0.05 MG/1 ML AMP 7/1/2015 99/99/9999 M0100078-0331-84 J0480 INJECTION, BASILIXIMAB SIMULECT 20 MG VIAL 7/1/2015 99/99/9999 M0100078-0393-61 J0480 INJECTION, BASILIXIMAB SIMULECT 10 MG VIAL 7/1/2015 99/99/9999 M0149401-0101-01 J0490 BELIMUMAB INJECTION BENLYSTA 120 MG VIAL 1/1/2012 99/99/9999 Y M0149401-0102-01 J0490 BELIMUMAB INJECTION BENLYSTA 400 MG VIAL 1/1/2012 99/99/9999 Y M0158914-0080-52 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG BENTYL 10 MG/ML AMPUL 7/1/2015 99/99/9999 M0160793-0700-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 600,000 UNIT/ML 1/1/2011 99/99/9999 M0160793-0131-10 J0561 PENICILLIN G BENZATHINE INJ PEN G 1.2 MILLION UNIT/2 ML 1/1/2011 99/99/9999 M0160793-0600-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN C-R 1.2 MILLION UNIT 1/1/2011 99/99/9999 M0160793-0701-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 1,200,000 UNITS 1/1/2011 99/99/9999 M0160793-0702-10 J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 2,400,000 UNITS 1/1/2011 99/99/9999 M0115054-0530-06 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 300 UNIT VIAL 4/1/2012 3/31/2013 M0115054-0500-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 500 UNITS VIAL 4/1/2012 3/31/2013 M0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/2012 99/99/9999 M0100023-9232-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 100 UNITS VIAL 4/1/2012 99/99/9999 M0100023-9232-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/2012 12/31/2012 M0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/2012 99/99/9999 M0100023-3919-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/2012 99/99/9999 M0100023-3921-02 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 200 UNITS VIAL 4/1/2012 99/99/9999 M0115054-0500-01 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 500 UNITS VIAL 4/1/2013 99/99/9999 M0115054-0530-06 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 300 UNIT VIAL 4/1/2013 99/99/9999 M0110454-0710-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 2,500 UNIT/0.5 ML VIAL 2/1/2013 99/99/9999 M0110454-0711-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 5,000 UNITS/1 ML VIAL 2/1/2013 99/99/9999 M0110454-0712-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 10,000 UNITS/2 ML VIAL 2/1/2013 99/99/9999 M0100259-1605-01 J0588 INCOBOTULINUMTOXIN A XEOMIN 50 UNITS VIAL 1/1/2012 99/99/9999 M0100259-1610-01 J0588 INCOBOTULINUMTOXIN A XEOMIN 100 UNITS VIAL 1/1/2012 99/99/9999 M0100409-2012-32 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENORPHINE 0.3 MG/ML SYRN 7/1/2015 99/99/9999 M0112496-0757-01 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENEX 0.3 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1623-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1626-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1626-02 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 7/1/2015 99/99/9999 M0163833-0825-02 J0598 C-1 ESTERASE, CINRYZE BERINERT 500 UNIT KIT 2/1/2013 99/99/9999 M0100517-3900-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0163323-0311-10 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0163323-0311-50 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0163323-0311-61 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 7/1/2015 99/99/9999 M0100078-0149-23 J0630 INJECTION, CALCITONIN SALMON, UP TO 400 MIACALCIN 200 UNIT/ML VIAL 7/1/2015 99/99/9999 M0100078-0582-61 J0638 CANAKINUMAB INJECTION ILARIS 180 MG VIAL 1/1/2013 99/99/9999 M0125021-0815-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 2/15/2013 99/99/9999 M0125021-0816-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 2/15/2013 99/99/9999 M0100703-5140-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 99/99/9999 M0100703-5145-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
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Schedule55390-0009-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 6/30/2013 M0155390-0051-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 50 MG VIAL 3/1/2008 8/31/2013 M0155390-0052-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 8/31/2014 M0155390-0053-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 4/30/2014 M0155390-0054-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 2/28/2015 M0155390-0818-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 8/31/2014 M0155390-0824-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 4/30/2014 M0155390-0825-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 5/31/2013 M0155390-0826-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 6/30/2013 M0163323-0711-00 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 500 MG VL 3/1/2008 99/99/9999 M0163323-0710-50 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 8/30/2011 99/99/9999 M0168152-0101-00 J0641 LEVOLEUCOVORIN INJECTION FUSILEV I.V. 50 MG VIAL 7/1/2015 99/99/9999 M0100409-1036-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 7/1/2015 99/99/9999 M0100409-1038-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 7/1/2015 99/99/9999 M0100409-1041-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1.5% VIAL 7/1/2015 99/99/9999 M0100409-1067-20 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 7/1/2015 99/99/9999 M0100409-2047-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 7/1/2015 99/99/9999 M0125021-0100-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100143-9923-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100143-9924-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100143-9983-91 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100264-3103-11 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM-D5W BAG 7/1/2015 99/99/9999 M0100338-3503-41 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM-D5W BAG 7/1/2015 99/99/9999 M0100409-2585-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM ADD-VAN VIAL 7/1/2015 99/99/9999 M0100781-3450-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0100781-3451-96 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0100781-3452-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0160505-0749-04 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0749-05 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0769-00 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0163323-0236-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 500 MG VIAL 7/1/2015 99/99/9999 M0163323-0237-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0163323-0238-61 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 10 GM VIAL 7/1/2015 99/99/9999 M0100409-0805-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 M CEFAZOLIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0681-00 J0692 INJECTION CEFEPIME HCL 2 GRAM VIAL 7/1/2015 99/99/9999 M0160505-0681-04 J0692 INJECTION CEFEPIME HCL 2 GRAM VIAL 7/1/2015 99/99/9999 M0160505-0834-00 J0692 INJECTION CEFEPIME HCL 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0834-04 J0692 INJECTION CEFEPIME HCL 1 GM VIAL 7/1/2015 99/99/9999 M0100264-3123-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM PIGGYBACK BAG 7/1/2015 99/99/9999 M0100264-3125-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM PIGGYBACK BAG 7/1/2015 99/99/9999 M0160505-0759-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM VIAL 7/1/2015 99/99/9999 M0160505-0760-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM VIAL 7/1/2015 99/99/9999 M0160505-0761-04 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 7/1/2015 99/99/9999 M0163323-0343-61 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 7/1/2015 99/99/9999 M0155390-0310-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2014 M0125021-0104-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 12/30/2008 12/31/2010 M0125021-0105-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/2008 99/99/9999 M0125021-0106-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 12/30/2008 99/99/9999 M0125021-0107-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 12/30/2008 99/99/9999 M0100517-8711-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/2/2008 12/31/2012 M0100517-8722-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/2/2008 12/31/2012 M0100517-8725-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/2008 12/31/2012 M0100517-8750-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/2008 12/31/2012 M0168330-0005-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/2/2008 9/30/2011 M0155390-0309-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 11/9/2009 12/31/2014 M0155390-0311-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/1/2009 12/31/2014 M0100069-4481-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2011 M0100069-4481-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/2009 12/31/2011 M0100069-4482-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/2012 M0100069-4482-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/2012 M0100703-0315-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 5/29/2008 1/31/2013 M0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/2011 M0100703-0335-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 4/30/2013 M0100703-0346-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 5/29/2008 1/31/2013 M0100703-0359-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 5/29/2008 1/31/2013 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00781-3208-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 99/99/9999 M0168330-0006-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 5/29/2008 9/30/2011 M0100781-9328-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100143-9856-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/30/2008 99/99/9999 M0100143-9857-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 1/1/2010 99/99/9999 M0100143-9858-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/2008 99/99/9999 M0100143-9859-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/2008 99/99/9999 M0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/2011 M0100004-1962-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/2008 M0100004-1963-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/2008 7/31/2014 M0100004-1963-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/2008 7/31/2014 M0100004-1964-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/2008 2/28/2015 M0100004-1964-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/2008 2/28/2015 M0100004-1965-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 2 GM VIAL 3/1/2008 8/31/2008 M0100004-1971-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 10 GM VIAL 3/1/2008 8/31/2008 M0100264-3153-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM-D5W BAG 3/1/2008 99/99/9999 M0100264-3155-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM-D5W BAG 3/1/2008 99/99/9999 M0100338-5002-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/2008 99/99/9999 M0100338-5003-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/2008 99/99/9999 M0100409-7332-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100409-7333-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100409-7333-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100409-7334-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0100409-7335-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0100409-7336-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/2008 99/99/9999 M0100409-7336-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/2008 99/99/9999 M0100409-7337-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0100409-7338-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-3206-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0100781-9326-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 7/31/2015 M0110019-0098-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0110019-0098-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0110019-0685-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 12/31/2011 M0110019-0685-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2013 M0110019-0686-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 12/31/2011 M0110019-0686-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2013 M0110019-0687-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 12/31/2011 M0110019-0687-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2013 M0110019-0688-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 12/31/2014 M0110019-0688-27 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 12/31/2014 M0110019-0689-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 12/31/2014 M0160505-0679-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0160505-0679-08 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/2008 99/99/9999 M0160505-0679-09 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/2008 99/99/9999 M0160505-0750-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0160505-0750-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0160505-0751-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0160505-0751-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0160505-0752-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0160505-0752-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0160505-0753-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0160505-0753-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0163323-0344-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0163323-0345-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0163323-0346-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0163323-0347-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0163323-0348-61 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0168180-0611-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0168180-0611-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0168180-0622-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0168180-0622-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0168180-0633-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0168180-0633-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0168180-0644-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0168180-0644-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule68330-0001-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 M0168330-0001-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 M0168330-0002-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011 M0168330-0002-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011 M0168330-0003-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2011 M0168330-0003-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/2011 M0168330-0004-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/2011 M0168330-0004-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/2011 M0164679-0701-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0164679-0701-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 99/99/9999 M0164679-0701-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2011 M0164679-0702-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0164679-0703-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0164679-0703-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0164679-0983-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0164679-0983-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0164679-0702-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-3207-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-3208-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100781-3209-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 99/99/9999 M0100781-3210-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 99/99/9999 M0100781-9327-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 99/99/9999 M0100781-9328-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 99/99/9999 M0100781-9329-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 8/31/2015 M0100781-9330-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 6/30/2015 M0100781-3206-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 7/17/2009 99/99/9999 M0100781-3207-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/2008 99/99/9999 M0100781-9326-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/30/2011 7/31/2015 M0100781-9327-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 8/16/2012 99/99/9999 M0100004-1962-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/2008 M0100143-9976-91 J0697 INJECTION, STERILE CEFUROXIME SODIUM, P CEFUROXIME SOD 7.5 GM VIAL 7/1/2015 99/99/9999 M0100143-9977-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM, P CEFUROXIME SOD 1.5 GM VIAL 7/1/2015 99/99/9999 M0100143-9979-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM, P CEFUROXIME SOD 750 MG VIAL 7/1/2015 99/99/9999 M0100039-0018-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 7/1/2015 1/31/2016 M0100039-0019-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 7/1/2015 1/31/2016 M0100039-0020-01 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 10 GM VIAL 7/1/2015 1/31/2016 M0100039-0023-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM ADD-VANTAGE VL 7/1/2015 7/31/2015 M0100039-0037-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM/50 ML GALAXY 7/1/2015 99/99/9999 M0100039-0038-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM/50 ML GALAXY 7/1/2015 99/99/9999 M0100143-9930-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 7/1/2015 99/99/9999 M0100143-9931-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 7/1/2015 99/99/9999 M0100143-9933-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 7/1/2015 99/99/9999 M0100143-9935-91 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 10 GM VIAL 7/1/2015 99/99/9999 M0100085-0566-05 J0702 INJECTION, BETAMETHASONE ACETATE CELESTONE SOLUSPAN 6 MG/ML 7/1/2015 99/99/9999 M0100456-0400-10 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 400 MG VIAL 1/1/2012 99/99/9999 M0100456-0600-01 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 600 MG VIAL 1/1/2012 99/99/9999 M0100456-0600-10 J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 600 MG VIAL 1/1/2012 99/99/9999 M0100409-5082-16 J0713 CEFTAZIDIME TAZICEF 1 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5082-52 J0713 CEFTAZIDIME TAZICEF 1 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5084-11 J0713 CEFTAZIDIME TAZICEF 2 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5084-51 J0713 CEFTAZIDIME TAZICEF 2 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5086-11 J0713 CEFTAZIDIME TAZICEF 6 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5086-51 J0713 CEFTAZIDIME TAZICEF 6 GRAM VIAL 7/1/2015 99/99/9999 M0100409-5092-16 J0713 CEFTAZIDIME TAZICEF 1 GM ADD-VANTAGE VIAL 7/1/2015 99/99/9999 M0100409-5092-52 J0713 CEFTAZIDIME TAZICEF 1 GM ADD-VANTAGE VIAL 7/1/2015 99/99/9999 M0100409-5093-11 J0713 CEFTAZIDIME TAZICEF 2 GM ADD-VANTAGE 7/1/2015 99/99/9999 M0100781-3177-96 J0713 CEFTAZIDIME CEFTAZIDIME 1 GM VIAL 7/1/2015 99/99/9999 M0100781-3178-95 J0713 CEFTAZIDIME CEFTAZIDIME 2 GM VIAL 7/1/2015 99/99/9999 M0100781-3179-86 J0713 CEFTAZIDIME CEFTAZIDIME 6 GM VIAL 7/1/2015 99/99/9999 M0163323-0011-15 J0720 INJECTION, CHLORAMPHENICOL SODIUM SUCCIN CHLORAMPHEN NA SUCC 1 GM VL 7/1/2015 99/99/9999 M0100052-0315-10 J0725 INJECTION, CHORIONIC GONADOTROPIN PREGNYL 10,000 UNITS VIAL 7/1/2015 99/99/9999 M0155566-1501-01 J0725 INJECTION, CHORIONIC GONADOTROPIN NOVAREL 10,000 UNITS VIAL 7/1/2015 99/99/9999 M0163323-0025-10 J0725 INJECTION, CHORIONIC GONADOTROPIN CHORIONIC GONAD 10,000 UNIT VL 7/1/2015 99/99/9999 M0100006-3514-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 7/1/2015 99/99/9999 M0100006-3516-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 7/1/2015 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00006-3551-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 7/1/2015 99/99/9999 M0100006-3552-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 7/1/2015 99/99/9999 M0100409-4765-86 J0744 INJECTION CIPROFLOXACIN 200 MG/20 ML VL 7/1/2015 99/99/9999 M0100409-4778-86 J0744 INJECTION CIPROFLOXACIN 400 MG/40 ML VL 7/1/2015 99/99/9999 M0100574-0858-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 7/1/2015 99/99/9999 M0139822-0615-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 7/1/2015 99/99/9999 M0155566-0302-01 J0795 INJECTION, CORTICORELIN OVINE TRIFLUTATE ACTHREL 100 MCG VIAL 7/1/2015 99/99/9999 M0163004-7731-01 J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS HP ACTHAR GEL 80 UNIT/ML VIAL 7/1/2015 99/99/9999 M0100781-3440-71 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG COSYNTROPIN 0.25 MG VIAL 7/1/2013 99/99/9999 M0100781-3052-95 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG COSYNTROPIN 0.25 MG/ML 1/1/2013 99/99/9999 M0100548-5900-00 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG CORTROSYN 0.25 MG VIAL 1/1/2013 12/31/2014 M0100548-5900-00 J0834 INJECTION, COSYNTROPIN, 0.25 MG CORTROSYN 0.25 MG VIAL 1/1/2014 12/31/2014 M0100281-0330-10 J0840 CROTALIDAE POLY IMMUNE FAB CROFAB VIAL 1/1/2012 6/30/2013 M0167919-0011-01 J0878 DAPTOMYCIN INJECTION CUBICIN 500 MG VIAL 7/1/2015 99/99/9999 M0155513-0002-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0002-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0003-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0003-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0004-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0004-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0005-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0005-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0006-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0021-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0021-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0023-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0023-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0025-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0025-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0027-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0027-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0028-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0032-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 500 MCG/1 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0053-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 7/1/2015 99/99/9999 M0155513-0053-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 7/1/2015 99/99/9999 M0155513-0057-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 7/1/2015 99/99/9999 M0155513-0057-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 7/1/2015 99/99/9999 M0155513-0110-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0111-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/0.6 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0025-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0027-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 150 MCG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0155513-0057-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/0.42 ML SYRING 7/1/2015 99/99/9999 M0155513-0002-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0003-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 40 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0005-01 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/ML VIAL 7/1/2015 99/99/9999 M0155513-0126-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0126-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0144-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0144-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0148-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0148-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0267-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0267-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0283-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 7/1/2015 99/99/9999 M0155513-0283-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 7/1/2015 99/99/9999 M0155513-0478-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0478-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0302-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 2,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0303-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 3,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0304-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 4,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0310-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0310-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0320-04 J0885 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0340-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 40,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0159676-0320-04 J0886 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 5/1/2011 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00078-0347-51 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL 2 GRAM VIAL 7/1/2015 99/99/9999 M0100078-0467-91 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL MESYLATE 500 MG VL 7/1/2015 99/99/9999 M0100409-2336-10 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 7/1/2015 99/99/9999 M0100409-2337-25 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 7/1/2015 99/99/9999 M0155513-0730-01 J0897 DENOSUMAB INJECTION XGEVA 120 MG/1.7 ML VIAL 1/1/2012 99/99/9999 M0155513-0710-01 J0897 DENOSUMAB INJECTION PROLIA 60 MG/ML SYRINGE 1/1/2012 99/99/9999 M0100009-0271-01 J1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP DEPO-ESTRADIOL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-02 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-51 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0280-52 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-3073-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-3073-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 DEPO-MEDROL 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100703-0031-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100703-0031-04 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100703-0043-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100703-0045-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 4 METHYLPREDNISOLONE 40 MG/ML VL 7/1/2015 99/99/9999 M0100781-3132-95 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/2010 99/99/9999 M0100781-3132-71 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/2010 99/99/9999 M0100781-3137-75 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100703-0051-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100703-0051-04 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100703-0063-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/2010 99/99/9999 M0100009-0306-12 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-0306-02 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-03 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3073-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3073-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-3475-23 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 99/99/9999 M0100009-0306-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/2010 3/31/2015 M0100009-0626-01 J1050 MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 400 MG/ML VIAL 7/1/2015 99/99/9999 M0100703-6801-01 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0100703-6801-04 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0100009-0746-30 J1050 MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0746-35 J1050 MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 7/1/2015 99/99/9999 M0159762-4537-02 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0159762-4537-01 J1050 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 7/1/2015 99/99/9999 M0100009-0347-02 J1071 INJ TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 100 MG/ML VL 1/1/2015 99/99/9999 M0100781-3073-70 J1071 INJ TESTOSTERONE CYPIONATE TESTOSTERONE CYP 100 MG/ML 1/1/2015 99/99/9999 M0100009-0417-01 J1071 INJ TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML 1/1/2015 99/99/9999 M0100009-0417-02 J1071 INJ TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML 1/1/2015 99/99/9999 M0100591-3223-79 J1071 INJ TESTOSTERONE CYPIONATE TESTOSTERON CYP 2,000 MG/10 ML 1/1/2015 5/31/2017 M0100641-0367-21 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/2/2008 99/99/9999 M0100069-4541-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/16/2012 8/31/2015 M0100069-4543-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/16/2012 3/31/2015 M0100069-4543-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/30/2011 3/31/2015 M0100069-4545-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 8/30/2011 4/30/2015 M0100069-4541-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/30/2011 8/31/2015 M0100517-4901-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/2008 12/31/2014 M0100517-4905-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/2008 12/31/2014 M0100517-4930-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/2008 12/31/2014 M0100641-0367-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 99/99/9999 M0100703-3524-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 2/28/2011 M0100703-3524-03 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 3/31/2011 M0163323-0165-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0165-05 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/2008 99/99/9999 M0163323-0165-30 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/2008 99/99/9999 M0163323-0506-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0516-10 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 3/1/2008 99/99/9999 M0100054-3176-44 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE INTENSOL 1MG/1ML 3/1/2008 99/99/9999 M0100574-0850-05 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 7/1/2015 99/99/9999 M0100574-0850-10 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 7/1/2015 99/99/9999 M0166490-0041-01 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG D.H.E.45 1 MG/ML AMPUL 7/1/2015 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00641-1410-35 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 500 MCG/2 ML AMPULE 7/1/2015 99/99/9999 M0100781-3059-95 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 500 MCG/2 ML AMPULE 7/1/2015 99/99/9999 M0100143-9881-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 250 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100143-9882-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 100 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100641-0493-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 7/1/2015 99/99/9999 M0100641-2555-45 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 7/1/2015 99/99/9999 M0117478-0540-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML VL 11/10/2010 99/99/9999 M0100409-2634-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 99/99/9999 M0100409-2634-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 50 MG/5 ML VIAL 6/1/2009 99/99/9999 M0100409-2634-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 500 MG/50 ML VIA 6/1/2009 99/99/9999 M0159011-0441-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0442-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0442-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0444-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0445-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0445-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/2009 99/99/9999 M0159011-0445-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML VIAL 6/1/2009 99/99/9999 M0159011-0446-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 250 MG VIAL 6/1/2009 99/99/9999 M0100074-2332-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 3/31/2011 M0100074-2333-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/31/2011 M0100074-2333-26 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/1/2011 M0100074-2334-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 3/31/2011 M0100074-2414-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML VIAL 6/1/2009 3/31/2010 M0100406-3245-52 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 M0100409-1283-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 1 MG/ML SYRINGE 6/1/2009 99/99/9999 M0100409-1304-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 4 MG/ML SYRIN 6/1/2009 99/99/9999 M0100409-1312-30 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML SYRINGE 6/1/2009 99/99/9999 M0100409-2172-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 7/1/2011 M0100409-2172-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 9/30/2011 M0100409-2540-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 4 MG/ML AMP 6/1/2009 99/99/9999 M0100409-2552-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 1 MG/ML AMP 6/1/2009 99/99/9999 M0100409-3356-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 2 MG/ML AMP 6/1/2009 99/99/9999 M0100409-3365-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0100555-1117-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 8/31/2011 M0100555-1117-06 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 9/30/2011 M0100555-1117-07 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 6/30/2011 M0100574-2017-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 M0100641-0121-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0100641-2341-41 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0138779-0731-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/2011 M0100641-0121-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/2009 99/99/9999 M0100409-2290-31 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML SYRNG 7/1/2015 99/99/9999 M0100641-0376-25 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0664-01 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0167457-0124-10 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0366-01 J1240 INJECTION, DIMENHYDRINATE, UP TO 50 MG DIMENHYDRINATE 50 MG/ML VIAL 7/1/2015 99/99/9999 M0100641-2569-44 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100338-1073-02 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1075-02 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1077-02 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 7/1/2015 99/99/9999 M0100409-2025-20 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2025-54 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2344-01 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2344-02 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2344-88 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2346-32 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-2347-32 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-3724-32 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 7/1/2015 99/99/9999 M0100088-1206-32 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 M0100088-1208-06 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 M0100088-1208-69 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 9/30/2013 M0100088-1208-76 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 7/1/2010 M0100088-1209-26 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/2008 99/99/9999 M0100338-1005-02 J1265 INJECTION, DOPAMINE HCL DOPAMINE 200 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1005-03 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 500 ML 7/1/2015 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00338-1007-02 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100338-1007-03 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 500 ML 7/1/2015 99/99/9999 M0100338-1009-02 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-5820-01 J1265 INJECTION, DOPAMINE HCL DOPAMINE 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-7808-22 J1265 INJECTION, DOPAMINE HCL DOPAMINE 200 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-7808-24 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 500 ML 7/1/2015 99/99/9999 M0100409-7809-22 J1265 INJECTION, DOPAMINE HCL DOPAMINE 400 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-7809-24 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 500 ML 7/1/2015 99/99/9999 M0100409-7810-22 J1265 INJECTION, DOPAMINE HCL DOPAMINE 800 MG-D5W 250 ML 7/1/2015 99/99/9999 M0100409-9104-20 J1265 INJECTION, DOPAMINE HCL DOPAMINE 40 MG/ML VIAL 7/1/2015 99/99/9999 M0100517-1305-25 J1265 INJECTION, DOPAMINE HCL DOPAMINE 160 MG/ML VIAL 7/1/2015 99/99/9999 M0100517-1905-25 J1265 INJECTION, DOPAMINE HCL DOPAMINE 80 MG/ML VIAL 7/1/2015 99/99/9999 M0158468-0126-01 J1270 INJECTION HECTOROL 2 MCG/ML VIAL 7/1/2015 99/99/9999 M0125682-0001-01 J1300 Eculizumab injection SOLIRIS 300 MG/30 ML VIAL 7/1/2015 99/99/9999 M0100173-0517-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 0.5 MG VIAL 7/7/2015 99/99/9999 M0100173-0519-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 1.5 MG VIAL 7/7/2015 99/99/9999 M0100006-3843-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM VIAL 7/1/2015 99/99/9999 M0100006-3845-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM ADD-VANTAGE VIAL 7/1/2015 99/99/9999 M0100409-6476-44 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG ADDVNT VL 7/1/2015 99/99/9999 M0100409-6482-01 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG VIAL 7/1/2015 99/99/9999 M0100046-0749-05 J1410 INJECTION, ESTROGEN CONJUGATED PREMARIN 25 MG VIAL 7/1/2015 99/99/9999 M0158406-0425-34 J1438 INJECTION, ETANERCEPT ENBREL 25 MG KIT 7/1/2015 99/99/9999 M0158406-0425-41 J1438 INJECTION, ETANERCEPT ENBREL 25 MG KIT 7/1/2015 99/99/9999 M0158406-0435-01 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SYRINGE 7/1/2015 99/99/9999 M0158406-0435-04 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SYRINGE 7/1/2015 99/99/9999 M0158406-0445-01 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SURECLICK SYR 7/1/2015 99/99/9999 M0158406-0445-04 J1438 INJECTION, ETANERCEPT ENBREL 50 MG/ML SURECLICK SYR 7/1/2015 99/99/9999 M0158406-0455-01 J1438 INJECTION, ETANERCEPT ENBREL 25 MG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0158406-0455-04 J1438 INJECTION, ETANERCEPT ENBREL 25 MG/0.5 ML SYRINGE 7/1/2015 99/99/9999 M0100517-0650-01 J1439 INJ FERRIC CARBOXYMALTOS 1MG INJECTAFER 750 MG/15 ML VIAL 1/1/2015 99/99/9999 M0155513-0209-01 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/0.8 ML SYR 1/1/2014 99/99/9999 M0155513-0209-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/0.8 ML SYR 1/1/2014 99/99/9999 M0155513-0546-01 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/1.6 ML VIAL 1/1/2014 99/99/9999 M0155513-0546-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 480 MCG/1.6 ML VIAL 1/1/2014 99/99/9999 M0155513-0924-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 300 MCG/0.5 ML SYR 1/1/2014 99/99/9999 M0155513-0530-01 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 300 MCG/ML VIAL 1/1/2014 99/99/9999 M0155513-0530-10 J1442 INJ, FILGRASTIM G-CSF 1MCG NEUPOGEN 300 MCG/ML VIAL 1/1/2014 99/99/9999 M0100338-6045-37 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100338-6046-48 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4684-02 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-DEXT 400 MG/200 ML 7/1/2015 99/99/9999 M0100409-4684-23 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-DEXT 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4688-02 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100409-4688-23 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4688-28 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100409-4688-34 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100703-1020-30 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 400 MG/200 ML 7/1/2015 99/99/9999 M0100703-1029-30 J1450 INJECTION, FLUCONAZOLE FLUCONAZOLE-NACL 200 MG/100 ML 7/1/2015 99/99/9999 M0100006-3941-32 J1453 FOSAPREPITANT INJECTION EMEND 150 MG VIAL 11/15/2010 99/99/9999 M0100006-3884-32 J1453 FOSAPREPITANT INJECTION EMEND 115 MG VIAL 11/1/2009 7/31/2012 M0168135-0020-01 J1458 INJECTION, GALSULFASE, 1 MG NAGLAZYME 5 MG/5 ML VIAL 7/1/2015 99/99/9999 M0113533-0635-04 J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR GAMASTAN S-D VIAL 7/1/2015 99/99/9999 M0113533-0635-12 J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR GAMASTAN S-D VIAL 7/1/2015 99/99/9999 M0164208-8234-01 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 1/31/2015 M0164208-8234-02 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 99/99/9999 M0164208-8234-03 J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/2012 99/99/9999 M0161953-0005-02 J1566 INJECTION, IMMUNE GLOBULIN FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 M0100944-2655-03 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 G (IGA<1) SOLN 3/1/2010 99/99/9999 M0100944-2655-04 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 G (IGA<1) SOL 3/1/2010 99/99/9999 M0100944-0471-75 J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 5 GM VIAL-DILUE 3/1/2010 12/31/2010 M0100944-0471-80 J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 10 GM VIAL-DILU 3/1/2010 12/31/2010 M0100944-2620-01 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 0.5 GM VL W-ST 3/1/2010 12/31/2012 M0100944-2620-02 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 2.5 GM VL W/ST 3/1/2010 5/25/2013 M0100944-2620-03 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 GM VL W/SET 3/1/2010 4/11/2014 M0100944-2620-04 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 GM VL W/ST 3/1/2010 6/21/2014 M0144206-0416-03 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 3 GM VIAL 3/1/2010 6/3/2014 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule44206-0417-06 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 6 GM VIAL 3/1/2010 99/99/9999 M0144206-0418-12 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 12 GM VIAL 3/1/2010 99/99/9999 M0164193-0250-50 J1566 INJECTION, IMMUNE GLOBULIN IVEEGAM EN 5 GM VIAL 3/1/2010 12/31/2010 M0100944-2700-02 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-03 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-04 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-05 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100944-2700-06 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 7/1/2015 99/99/9999 M0100004-6940-03 J1570 INJECTION, GANCICLOVIR SODIUM CYTOVENE 500 MG VIAL 7/1/2015 99/99/9999 M0161953-0005-02 J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 M0161953-0005-03 J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 11/15/2010 99/99/9999 M0161953-0003-01 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0003-02 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0003-03 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0003-04 J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/2009 12/31/2010 M0161953-0004-01 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-02 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-03 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-04 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0161953-0004-05 J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/2009 99/99/9999 M0100338-0503-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 80 MG/100 ML 7/1/2015 99/99/9999 M0100338-0505-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISO GENTAMICIN 100 MG/100 ML 7/1/2015 99/99/9999 M0100338-0507-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 60 MG/50 ML 7/1/2015 99/99/9999 M0100338-0507-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISO GENTAMICIN 120 MG/100 ML 7/1/2015 99/99/9999 M0100338-0509-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 80 MG/50 ML 7/1/2015 99/99/9999 M0100338-0511-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 100 MG/50 ML 7/1/2015 99/99/9999 M0100409-1207-03 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100409-7879-13 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 60 MG/NS 50 ML PB 7/1/2015 99/99/9999 M0100409-7883-13 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 50 ML PB 7/1/2015 99/99/9999 M0100409-7884-23 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 100 ML PB 7/1/2015 99/99/9999 M0100409-7889-23 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 100 MG/NS 100 ML 7/1/2015 99/99/9999 M0163323-0010-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0010-20 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 40 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0173-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN PED 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0513-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100002-8031-01 J1610 INJECTION,GLUCAGON GLUCAGON 1 MG EMERGENCY KIT 7/1/2015 99/99/9999 M0100169-7065-15 J1610 INJECTION,GLUCAGON GLUCAGEN 1 MG HYPOKIT 7/1/2015 99/99/9999 M0155390-0004-01 J1610 INJECTION,GLUCAGON GLUCAGEN DIAGNOSTIC 1 MG VIAL 7/1/2015 99/99/9999 M0155390-0004-10 J1610 INJECTION,GLUCAGON GLUCAGEN DIAGNOSTIC 1 MG VIAL 7/1/2015 99/99/9999 M0155390-0250-10 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 9/30/2011 M0163323-0318-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 M0163323-0319-04 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 99/99/9999 M0166758-0035-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 M0166758-0036-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 99/99/9999 M0166758-0037-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 12/31/2010 M0100703-7973-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 1/1/2010 99/99/9999 M0163323-0317-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/2010 99/99/9999 M0100703-7871-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 1/1/2010 8/31/2010 M0100703-7891-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/2010 12/31/2010 M0100703-7971-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/2009 99/99/9999 M0110019-0053-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 6/28/2010 M0160505-0764-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 99/99/9999 M0100004-0239-09 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 1 MG/ML VIAL 6/1/2009 7/31/2010 M0100004-0240-09 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 4 MG/4 ML VIAL 6/1/2009 11/30/2011 M0100004-0242-08 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 0.1 MG/ML VIAL 6/1/2009 3/31/2010 M0100703-7045-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0474-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0474-10 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0474-91 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100045-0253-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/2011 M0100045-0253-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/2011 M0100045-0254-14 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 100 AMPUL 3/1/2008 5/31/2011 M0100703-7011-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0100703-7013-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0100703-7021-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00703-7023-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0155390-0412-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/2011 M0155390-0412-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/2011 M0155390-0413-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/2011 M0155390-0413-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/2011 M0160505-0702-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0160505-0703-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0469-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0469-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0471-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0471-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 99/99/9999 M0150458-0253-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 11/10/2010 99/99/9999 M0167386-0701-54 J1640 INJECTION, HEMIN PANHEMATIN 313 MG VIAL 7/1/2015 9/30/2015 M0100264-9567-10 J1644 INJECTION, HEPARIN HEPARIN-D5W 20,000 UNIT/500 ML 7/1/2015 99/99/9999 M0100264-9577-10 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/500 ML 7/1/2015 99/99/9999 M0100264-9587-20 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/250 ML 7/1/2015 99/99/9999 M0100264-9872-10 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 7/1/2015 99/99/9999 M0100338-0431-03 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 7/1/2015 99/99/9999 M0100338-0433-04 J1644 INJECTION, HEPARIN HEPARIN-NS 2,000 UNIT/1,000 ML 7/1/2015 99/99/9999 M0100409-1316-32 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/0.5 ML 7/1/2015 99/99/9999 M0100409-7620-03 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 7/1/2015 99/99/9999 M0100409-7620-59 J1644 INJECTION, HEPARIN HEPARIN-NS 2,000 UNIT/1,000 ML 7/1/2015 99/99/9999 M0100409-7650-62 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 25,000 UNITS/250 7/1/2015 99/99/9999 M0100409-7651-03 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 25,000 UNITS/500 7/1/2015 99/99/9999 M0100409-7651-62 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 12,500 UNITS/250 7/1/2015 99/99/9999 M0100409-7793-62 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/250 ML 7/1/2015 99/99/9999 M0100409-7794-62 J1644 INJECTION, HEPARIN HEPARIN-D5W 12,500 UNIT/250 ML 7/1/2015 99/99/9999 M0163323-0047-10 J1644 INJECTION, HEPARIN HEPARIN 50,000 UNITS/10 ML VL 7/1/2015 99/99/9999 M0163323-0262-01 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/ML VIAL 7/1/2015 99/99/9999 M0163323-0276-02 J1644 INJECTION, HEPARIN HEPARIN 2,000 UNIT/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0540-01 J1644 INJECTION, HEPARIN HEPARIN SOD 1,000 UNIT/ML VIAL 7/1/2015 99/99/9999 M0163323-0540-11 J1644 INJECTION, HEPARIN HEPARIN 10,000 UNIT/10 ML VIAL 7/1/2015 99/99/9999 M0163323-0540-31 J1644 INJECTION, HEPARIN HEPARIN 30,000 UNIT/30 ML VIAL 7/1/2015 99/99/9999 M0163323-0542-01 J1644 INJECTION, HEPARIN HEPARIN SOD 10,000 UNIT/ML VL 7/1/2015 99/99/9999 M0163323-0542-07 J1644 INJECTION, HEPARIN HEPARIN 50,000 UNITS/5 ML VIAL 7/1/2015 99/99/9999 M0163323-0915-01 J1644 INJECTION, HEPARIN HEPARIN SOD 20,000 UNIT/ML VL 7/1/2015 99/99/9999 M0162856-0101-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 10,000 UNITS/ML SYRING 7/1/2015 99/99/9999 M0162856-0125-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 12,500 UNITS/0.5 ML 7/1/2015 99/99/9999 M0162856-0150-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 15,000 UNITS/0.6 ML 7/1/2015 99/99/9999 M0162856-0180-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 18,000 UNITS/0.72 ML 7/1/2015 99/99/9999 M0162856-0250-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 2,500 UNITS/0.2 ML SYR 7/1/2015 99/99/9999 M0162856-0251-01 J1645 INJECTION, DALTEPARIN NA FRAGMIN 25,000 UNITS/ML VIAL 7/1/2015 99/99/9999 M0162856-0500-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 5,000 UNITS/0.2 ML SYR 7/1/2015 99/99/9999 M0162856-0750-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 7,500 UNITS/0.3 ML SYR 7/1/2015 99/99/9999 M0100075-0620-40 J1650 ENOXAPARIN SODIUM LOVENOX 40 MG/0.4 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0621-60 J1650 ENOXAPARIN SODIUM LOVENOX 60 MG/0.6 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0622-80 J1650 ENOXAPARIN SODIUM LOVENOX 80 MG/0.8 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0623-00 J1650 ENOXAPARIN SODIUM LOVENOX 100 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100075-0624-30 J1650 ENOXAPARIN SODIUM LOVENOX 30 MG/0.3 ML SYRINGE 7/1/2015 99/99/9999 M0100075-0626-03 J1650 ENOXAPARIN SODIUM LOVENOX 300 MG/3 ML VIAL 7/1/2015 99/99/9999 M0100075-2912-01 J1650 ENOXAPARIN SODIUM LOVENOX 120 MG/0.8 ML SYRINGE 7/1/2015 99/99/9999 M0100075-2915-01 J1650 ENOXAPARIN SODIUM LOVENOX 150 MG/ML SYRINGE 7/1/2015 99/99/9999 M0113533-0634-02 J1670 INJECTION, TETANUS IMMUNE GLOBULIN, HUMA HYPERTET S-D 250 UNITS SYRINGE 7/1/2015 99/99/9999 M0100009-0825-01 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 100 MG VIAL 7/1/2015 99/99/9999 M0164011-0243-01 J1725 HYDROXYPROGESTERONE CAPROATE MAKENA 1,250 MG/5 ML VIAL 1/1/2012 99/99/9999 M0100517-0750-01 J1725 HYDROXYPROGESTERONE CAPROATE PROGESTERONE OIL 50 MG/ML VL 1/1/2012 99/99/9999 M0100009-3794-01 J1742 INJECTION, IBUTILIDE FUMARATE CORVERT 1 MG/10 ML VIAL 7/1/2015 99/99/9999 M0154092-0700-01 J1743 Idursulfase injection ELAPRASE 6 MG/3 ML VIAL 7/1/2015 99/99/9999 M0157894-0030-01 J1745 INJECTION, INFLIZIMAB REMICADE 100 MG VIAL 7/1/2015 99/99/9999 M0152544-0931-02 J1750 INJECTION, IRON DEXTRAN INFED 100 MG/2 ML VIAL 1/1/2010 99/99/9999 M0149230-0534-10 J1750 INJECTION, IRON DEXTRAN VENOFER 100 MG/5 ML VIAL 1/1/2010 99/99/9999 M0100517-0234-10 J1750 INJECTION, IRON DEXTRAN DEXFERRUM 100 MG/2 ML VIAL 1/1/2010 3/31/2014 M0100517-2310-05 J1756 INJECTION, IRON SUCROSE VENOFER 200 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100517-2340-10 J1756 INJECTION, IRON SUCROSE VENOFER 100 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100517-2340-25 J1756 INJECTION, IRON SUCROSE VENOFER 100 MG/5 ML VIAL 7/1/2015 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule49230-0530-10 J1756 INJECTION, IRON SUCROSE VENOFER 50 MG/2.5 ML VIAL 7/1/2015 99/99/9999 M0149230-0530-25 J1756 INJECTION, IRON SUCROSE VENOFER 50 MG/2.5 ML VIAL 7/1/2015 99/99/9999 M0149230-0534-10 J1756 INJECTION, IRON SUCROSE VENOFER 100 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100409-1187-01 J1790 INJECTION, DROPERIDOL, UP TO 5 MG DROPERIDOL 2.5 MG/ML AMPUL 7/1/2015 99/99/9999 M0100517-9702-25 J1790 INJECTION, DROPERIDOL, UP TO 5 MG DROPERIDOL 2.5 MG/ML VIAL 7/1/2015 99/99/9999 M0100781-3777-95 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG PROPRANOLOL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0604-01 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG PROPRANOLOL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100002-7511-01 J1815 INJECTION, INSULIN HUMALOG MIX 75-25 VIAL 7/1/2015 99/99/9999 M0100002-7512-01 J1815 INJECTION, INSULIN HUMALOG MIX 50-50 VIAL 7/1/2015 99/99/9999 M0100002-7516-59 J1815 INJECTION, INSULIN HUMALOG 100 UNITS/ML CARTRIDGE 7/1/2015 99/99/9999 M0100002-8215-01 J1815 INJECTION, INSULIN HUMULIN R 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100002-8315-01 J1815 INJECTION, INSULIN HUMULIN N 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100002-8501-01 J1815 INJECTION, INSULIN HUMULIN R 500 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100002-8715-01 J1815 INJECTION, INSULIN HUMULIN 70-30 VIAL 7/1/2015 99/99/9999 M0100002-8730-59 J1815 INJECTION, INSULIN HUMULIN N 100 UNITS/ML PEN 7/1/2015 10/31/2015 M0100002-8770-59 J1815 INJECTION, INSULIN HUMULIN 70-30 PEN 7/1/2015 10/31/2015 M0100088-2220-33 J1815 INJECTION, INSULIN LANTUS 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100088-2220-60 J1815 INJECTION, INSULIN LANTUS SOLOSTAR 100 UNITS/ML 7/1/2015 99/99/9999 M0100169-1833-11 J1815 INJECTION, INSULIN NOVOLIN R 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100169-1834-11 J1815 INJECTION, INSULIN NOVOLIN N 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100169-1837-11 J1815 INJECTION, INSULIN NOVOLIN 70-30 100 UNIT/ML VIAL 7/1/2015 99/99/9999 M0100169-3303-12 J1815 INJECTION, INSULIN NOVOLOG 100 UNIT/ML CARTRIDGE 7/1/2015 99/99/9999 M0100169-3685-12 J1815 INJECTION, INSULIN NOVOLOG MIX 70-30 VIAL 7/1/2015 99/99/9999 M0100169-3696-19 J1815 INJECTION, INSULIN NOVOLOG MIX 70-30 FLEXPEN SYRN 7/1/2015 99/99/9999 M0100169-6339-10 J1815 INJECTION, INSULIN NOVOLOG 100 UNITS/ML FLEXPEN 7/1/2015 99/99/9999 M0100002-7510-01 J1817 INSULIN ADMIN THROUGH DME HUMALOG 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100088-2500-33 J1817 INSULIN ADMIN THROUGH DME APIDRA 100 UNITS/ML VIAL 7/1/2015 99/99/9999 M0100169-7501-11 J1817 INSULIN ADMIN THROUGH DME NOVOLOG 100 UNIT/ML VIAL 7/1/2015 99/99/9999 M0163323-0359-03 J1840 INJECTION, KANAMYCIN SULFATE, UP TO 500 KANAMYCIN 1 GM/3 ML VIAL 7/1/2015 99/99/9999 M0110019-0030-12 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 5/15/2009 5/31/2013 M0100409-2287-21 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML ISECURE SYR 3/1/2008 4/1/2012 M0100409-2287-22 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2ML ISECURE 3/1/2008 10/1/2011 M0100409-2287-31 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 99/99/9999 M0100409-2287-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 99/99/9999 M0100409-2288-21 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML ISECURE SYR 3/1/2008 12/31/2012 M0100409-2288-31 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML CARPUJECT 3/1/2008 99/99/9999 M0100409-3793-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3793-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3795-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3795-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 M0100409-3795-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 9/30/2011 M0100409-3796-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 M0100409-3796-49 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 M0100409-3796-61 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 7/1/2011 M0110019-0021-09 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML SYRINGE 3/1/2008 3/31/2010 M0110019-0022-09 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML SYRINGE 3/1/2008 3/31/2010 M0110019-0022-32 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC IM 30 MG/ML SYRING 3/1/2008 3/31/2010 M0110019-0029-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 10/31/2013 M0110019-0030-03 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 5/31/2013 M0110019-0030-04 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 8/31/2013 M0155390-0480-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 3/31/2013 M0155390-0481-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 11/30/2013 M0155390-0481-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 3/31/2013 M0155390-0481-10 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 300 MG/10 ML VIAL 3/1/2008 3/31/2014 M0163323-0161-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0162-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 99/99/9999 M0163323-0162-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 99/99/9999 M0164679-0757-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 3/31/2015 M0164679-0757-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/2008 3/31/2015 M0164679-0758-01 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 4/30/2015 M0164679-0758-02 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 2/28/2015 M0164679-0758-04 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 3/31/2015 M0164679-0758-05 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 3/31/2010 M0164679-0758-06 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 2/28/2015 M0100074-2287-54 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/2008 9/30/2014 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00003-0293-05 J1885 KETOROLAC TROMETHAMINE, PER 15 MG KENALOG-40 40 MG/ML VIAL 3/1/2008 99/99/9999 M0158468-0070-01 J1931 LARONIDASE INJECTION ALDURAZYME 2.9 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100409-1639-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 10 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-6102-02 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100409-6102-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 40 MG/4 ML VIAL 7/1/2015 99/99/9999 M0100409-6102-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 100 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-9631-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 10 MG/ML SYRINGE 7/1/2015 99/99/9999 M0163323-0280-02 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 20 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0280-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 40 MG/4 ML VIAL 7/1/2015 99/99/9999 M0163323-0280-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 100 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100074-3663-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 11.25 MG 3MO KIT 1/1/2012 99/99/9999 M0100074-3346-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 22.5 MG 3MO KIT 1/1/2012 99/99/9999 M0100074-3641-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 3.75 MG KIT 1/1/2012 99/99/9999 M0139822-4000-01 J1953 LEVETIRACETAM INJECTION LEVETIRACETAM 500 MG/5 ML VIAL 7/1/2015 99/99/9999 M0150474-0002-63 J1953 LEVETIRACETAM INJECTION KEPPRA 500 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100703-0404-02 J1955 LEVOCARNITINE LEVOCARNITINE 200 MG/ML VIAL 7/1/2015 99/99/9999 M0100703-0405-02 J1955 LEVOCARNITINE LEVOCARNITINE 200 MG/ML VIAL 7/1/2015 99/99/9999 M0154482-0147-01 J1955 LEVOCARNITINE CARNITOR 1 GM/5 ML VIAL 7/1/2015 99/99/9999 M0100264-9594-10 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100264-9594-20 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100264-9598-20 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 7/1/2015 99/99/9999 M0100338-0409-03 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100338-0411-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 7/1/2015 99/99/9999 M0100409-1323-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% SYRINGE 7/1/2015 99/99/9999 M0100409-2066-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100409-4056-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1.5% AMPUL 7/1/2015 99/99/9999 M0100409-4270-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4275-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 0.5% VIAL 7/1/2015 99/99/9999 M0100409-4276-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4276-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4277-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100409-4277-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100409-4278-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 0.5% VIAL 7/1/2015 99/99/9999 M0100409-4279-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0100409-4282-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% AMPUL 7/1/2015 99/99/9999 M0100409-4282-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% AMPUL 7/1/2015 99/99/9999 M0100409-4283-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 4% AMPUL 7/1/2015 99/99/9999 M0100409-4713-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% AMPUL 7/1/2015 99/99/9999 M0100409-4713-32 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% AMPUL 7/1/2015 99/99/9999 M0100409-4776-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1.5% AMPUL 7/1/2015 99/99/9999 M0100409-4903-34 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% ABBOJECT 7/1/2015 99/99/9999 M0100409-4904-34 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% ABBOJECT 7/1/2015 99/99/9999 M0100409-7931-32 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 7/1/2015 99/99/9999 M0100409-9137-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% SYRINGE 7/1/2015 99/99/9999 M0163323-0201-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0163323-0201-10 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 7/1/2015 99/99/9999 M0163323-0202-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0163323-0208-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 7/1/2015 99/99/9999 M0100009-0555-01 J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG LINCOCIN 300 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-0555-02 J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG LINCOCIN 300 MG/ML VIAL 7/1/2015 99/99/9999 M0100009-5137-01 J2020 INJECTION ZYVOX 200 MG/100 ML IV SOLN 7/1/2015 99/99/9999 M0100009-5140-01 J2020 INJECTION ZYVOX 600 MG/300 ML IV SOLN 7/1/2015 99/99/9999 M0100409-1539-31 J2060 INJECTION, LORAZEPAM LORAZEPAM 4 MG/ML CARPUJECT 7/1/2015 99/99/9999 M0100409-1985-30 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML CARPUJECT 7/1/2015 99/99/9999 M0100409-6778-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-6779-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 4 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-6780-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-6781-02 J2060 INJECTION, LORAZEPAM LORAZEPAM 4 MG/ML VIAL 7/1/2015 99/99/9999 M0117478-0040-01 J2060 INJECTION, LORAZEPAM LORAZEPAM 2 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-4031-01 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL 25% VIAL 7/1/2015 99/99/9999 M0163323-0024-25 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL 25% VIAL 7/1/2015 99/99/9999 M0115054-1040-05 J2170 INJECTION, MECASERMIN, 1 MG INCRELEX 40 MG/4 ML VIAL 7/1/2015 99/99/9999 M0100409-1176-30 J2175 INJECTION, MEPERIDINE DEMEROL 25 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-1178-30 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-1179-30 J2175 INJECTION, MEPERIDINE DEMEROL 75 MG/ML SYRINGE 7/1/2015 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00409-1180-69 J2175 INJECTION, MEPERIDINE DEMEROL 100 MG/ML SYRINGE 7/1/2015 99/99/9999 M0100409-1181-30 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1201-20 J2175 INJECTION, MEPERIDINE DEMEROL 100 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1203-01 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1253-01 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1254-01 J2175 INJECTION, MEPERIDINE DEMEROL 75 MG/1.5 ML AMPUL 7/1/2015 99/99/9999 M0100409-1255-02 J2175 INJECTION, MEPERIDINE DEMEROL 50 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1256-01 J2175 INJECTION, MEPERIDINE DEMEROL 100 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-6030-04 J2175 INJECTION, MEPERIDINE MEPERIDINE 10 MG/ML CARTRDGE 7/1/2015 99/99/9999 M0100310-0321-30 J2185 MEROPENEM INJECTION MERREM IV 1 GM VIAL 7/1/2015 99/99/9999 M0100310-0325-20 J2185 MEROPENEM INJECTION MERREM IV 500 MG VIAL 7/1/2015 99/99/9999 M0100469-3211-10 J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG MYCAMINE 100 MG VIAL 7/1/2015 99/99/9999 M0100469-3250-10 J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG MYCAMINE 50 MG VIAL 7/1/2015 99/99/9999 M0100409-2305-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2305-50 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 1 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2306-62 J2250 MIDAZOLAM HCL MIDAZOLAM 2 MG/2 ML CARPUJECT 7/1/2015 99/99/9999 M0100409-2307-60 J2250 MIDAZOLAM HCL MIDAZOLAM 5 MG/ML CARPUJECT 7/1/2015 99/99/9999 M0100409-2308-01 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2308-02 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2308-49 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2308-50 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/2 ML VIAL 7/1/2015 99/99/9999 M0100409-2587-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-2587-53 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-2596-03 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2596-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2596-52 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-2596-53 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0411-10 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/10 ML VIAL 7/1/2015 99/99/9999 M0163323-0411-12 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 2 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0411-25 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/5 ML VIAL 7/1/2015 99/99/9999 M0163323-0412-02 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/2 ML VIAL 7/1/2015 99/99/9999 M0163323-0412-05 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0412-10 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0163323-0412-25 J2250 MIDAZOLAM HCL MIDAZOLAM HCL 5 MG/ML VIAL 7/1/2015 99/99/9999 M0100338-6010-48 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 20 MG/100 ML 7/1/2015 99/99/9999 M0100338-6011-37 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 40 MG/200 ML 7/1/2015 99/99/9999 M0100409-2776-02 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 40 MG/200 ML 7/1/2015 99/99/9999 M0100409-2776-23 J2260 INJECTION, MILRINONE LACTATE MILRINONE-D5W 20 MG/100 ML 7/1/2015 99/99/9999 M0160505-0718-00 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 10 MG/10 ML VL 7/1/2015 99/99/9999 M0160505-0718-01 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 20 MG/20 ML VL 7/1/2015 99/99/9999 M0163323-0617-10 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 10 MG/10 ML VL 7/1/2015 99/99/9999 M0163323-0617-20 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 20 MG/20 ML VL 7/1/2015 99/99/9999 M0163323-0617-50 J2260 INJECTION, MILRINONE LACTATE MILRINONE LACT 50 MG/50 ML VL 7/1/2015 99/99/9999 M0100409-3815-12 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML VIAL P-F 7/1/2015 99/99/9999 M0100409-6177-14 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE SULFATE 25 MG/ML VL 7/1/2015 99/99/9999 M0100409-6179-14 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE SULFATE 25 MG/ML VL 7/1/2015 99/99/9999 M0100548-1911-25 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML SYRINGE 7/1/2015 8/31/2015 M0100409-1463-01 J2300 NALBUPHINE HCL NALBUPHINE 10 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1464-01 J2300 NALBUPHINE HCL NALBUPHINE 100 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-1465-01 J2300 NALBUPHINE HCL NALBUPHINE 20 MG/ML AMPUL 7/1/2015 99/99/9999 M0100409-1467-01 J2300 NALBUPHINE HCL NALBUPHINE 200 MG/10 ML VIAL 7/1/2015 99/99/9999 M0100409-1215-01 J2310 NALOXONE HCL NALOXONE 0.4 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1219-01 J2310 NALOXONE HCL NALOXONE 0.4 MG/ML VIAL 7/1/2015 99/99/9999 M0100409-1782-69 J2310 NALOXONE HCL NALOXONE 0.4 MG/ML SYRINGE 7/1/2015 99/99/9999 M0165757-0300-01 J2315 INJECTION, NALTREXONE, DEPOT FORM, 1 MG VIVITROL 380 MG VIAL + DILUENT 7/1/2010 99/99/9999 M0159075-0730-15 J2323 Natalizumab injection TYSABRI 300 MG/15 ML VIAL 7/1/2015 10/31/2016 M0165847-0205-25 J2325 INJECTION, NESIRITIDE NATRECOR 1.5 MG VIAL 7/1/2015 99/99/9999 M0100078-0340-61 J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 10 MG KIT 11/1/2011 99/99/9999 M0100078-0341-61 J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 20 MG KIT 11/1/2011 99/99/9999 M0100078-0342-61 J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 30 MG KIT 11/1/2011 99/99/9999 M0150242-0040-62 J2357 OMALIZOMAB, INJECTION XOLAIR 150 MG VIAL 7/1/2015 99/99/9999 M0100591-3222-47 J2360 INJECTION, ORPHENADRINE, UP TO 60 MG ORPHENADRINE 30 MG/ML AMPULE 7/1/2015 99/99/9999 M0117478-0538-02 J2360 INJECTION, ORPHENADRINE, UP TO 60 MG ORPHENADRINE 30 MG/ML VIAL 7/1/2015 99/99/9999 M0166758-0016-03 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 7/1/2015 99/99/9999 M0166758-0016-04 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 7/1/2015 7/31/2016 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule66758-0017-01 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 7/1/2015 9/30/2016 M0155150-0125-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 10/1/2013 99/99/9999 M0100641-6080-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 8/29/2012 99/99/9999 M0100641-6080-25 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 3/8/2012 99/99/9999 M0123155-0168-31 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 2/15/2013 99/99/9999 M0110019-0905-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 9/9/2009 9/30/2013 M0100781-5238-64 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/2009 99/99/9999 M0100781-5239-80 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 8 MG TABLET 6/1/2009 99/99/9999 M0100409-4755-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 M0100409-4755-63 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 M0100781-3010-95 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 M0110019-0905-17 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2013 M0100143-9771-06 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 2/8/2011 99/99/9999 M0100143-9890-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 M0100143-9891-05 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 M0100173-0442-00 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 2 MG/ML VIAL 6/1/2009 99/99/9999 M0100173-0442-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 4 MG/2 ML VIAL 6/1/2009 3/31/2012 M0100338-1762-41 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 32 MG/50 ML BAG 6/1/2009 10/31/2012 M0100409-1120-62 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML SYR 6/1/2009 3/1/2013 M0100409-4755-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 M0100409-4755-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 M0100409-4755-61 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/2010 M0100409-4755-62 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/2010 M0100409-4759-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 M0100409-4760-13 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/2009 9/30/2011 M0100703-7221-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 6/30/2011 M0100703-7221-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 12/10/2009 M0100703-7221-04 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 M0100703-7226-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 M0100703-7226-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 M0100703-7239-39 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/2009 12/31/2012 M0100781-3057-14 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 8/31/2011 M0100781-3057-80 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 1/31/2010 M0110019-0905-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2013 M0110019-0906-03 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 7/31/2013 M0110019-0906-04 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/24/2009 12/31/2011 M0155390-0121-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 3/31/2014 M0155390-0121-10 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 M0155390-0307-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/2011 M0155390-0307-10 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 12/31/2010 M0160505-0744-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 M0160505-0744-06 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 M0161703-0244-07 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/2011 M0161703-0245-22 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/2011 M0163323-0373-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 M0163323-0374-20 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 99/99/9999 M0164679-0726-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 11/30/2014 M0164679-0727-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 3/31/2015 M0100781-3010-72 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 99/99/9999 M0168462-0157-13 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/2009 99/99/9999 M0100409-1120-12 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 4 MG/2 ML ISECURE 7/1/2013 99/99/9999 M0100781-5257-31 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG TABLET 6/1/2009 1/31/2013 M0166860-0088-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 2/26/2010 12/31/2010 M0110019-0905-02 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 1/1/2010 9/30/2013 M0100641-6078-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 11/1/2011 99/99/9999 M0100641-6078-25 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 3/8/2012 99/99/9999 M0100409-3795-01 J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG KETOROLAC 30 MG/ML VIAL 6/1/2009 99/99/9999 M0163481-0624-10 J2410 INJECTION, OXYMORPHONE HCL, UP TO 1 MG OPANA 1 MG/ML INJ AMPULE 7/1/2015 99/99/9999 M0140042-0019-10 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 2/26/2010 12/31/2012 M0100078-0463-91 J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 30 MG VIAL 3/1/2008 2/29/2012 M0100078-0464-61 J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 90 MG VIAL 3/1/2008 9/30/2011 M0100703-4075-19 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIA 3/1/2008 99/99/9999 M0100703-4075-59 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 99/99/9999 M0100703-4085-11 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIA 3/1/2008 99/99/9999 M0100703-4085-51 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 99/99/9999 M01
Updated 8.11.15
NDC HCPCS HCPCS Description NDC DescriptionEffective
Date End DateX-Over
OnlyFee
Schedule00781-3147-84 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 2/28/2010 M0100781-3148-70 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 5/31/2010 M0115210-0401-11 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 3/31/2010 M0115210-0402-11 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 3/31/2010 M0155390-0127-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 3/31/2014 M0155390-0129-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 3/31/2014 M0155390-0157-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 8/31/2012 M0155390-0159-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 8/31/2012 M0155390-0204-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 9/30/2011 M0155390-0604-01 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 9/30/2011 M0161703-0324-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 99/99/9999 M0161703-0324-39 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 9/30/2011 M0161703-0325-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 60 MG/10 ML VIAL 3/1/2008 99/99/9999 M0161703-0326-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 99/99/9999 M0161703-0356-18 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 99/99/9999 M0163323-0734-10 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 99/99/9999 M0163323-0734-35 J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 3 MG/ML VIA 3/1/2008 99/99/9999 M0163323-0735-10 J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 99/99/9999 M0163323-0735-35 J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 9 MG/ML VIA 3/1/2008 3/31/2010 M0100517-4002-25 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE 60 MG/2 ML VIAL 7/1/2015 99/99/9999 M0162856-0797-01 J2469 ALOXI ALOXI 0.25 MG/5 ML VIAL 7/1/2015 99/99/9999 M0100074-1658-01 J2501 INJECTION, PARICALCITOL ZEMPLAR 5 MCG/ML VIAL 7/1/2015 99/99/9999 M0100074-4637-01 J2501 INJECTION, PARICALCITOL ZEMPLAR 2 MCG/ML VIAL 7/1/2015 99/99/9999 M0100074-1658-05 J2501 INJECTION, PARICALCITOL ZEMPLAR 10 MCG/2 ML VIAL 7/1/2015 99/99/9999 M0168782-0001-02 J2503 INJECTION, PEGAPTANIB SODIUM MACUGEN 0.3 MG/90 MICROLITERS 7/1/2015 99/99/9999 M0157665-0001-01 J2504 INJECTION, PEGADEMASE BOVINE ADAGEN 250 UNITS/ML VIAL 7/1/2015 99/99/9999 M0155513-0192-01 J2505 PEGFILGRASTIM NEULASTA 6 MG/0.6 ML DLVRY KIT 2/2/2015 99/99/9999 M0155513-0190-01 J2505 PEGFILGRASTIM NEULASTA 6 MG/0.6 ML SYRINGE 1/15/2015 99/99/9999 M0154396-0801-01 J2507 PEGLOTICASE INJECTION KRYSTEXXA 8 MG/ML VIAL 1/1/2012 99/99/9999 M0160793-0130-10 J2510 INJECTION, PENICILLIN G PROCAINE, AQUEOU PENICILLIN G 600,000 UNIT/1 ML 7/1/2015 99/99/9999 M0160793-0131-10 J2510 INJECTION, PENICILLIN G PROCAINE, AQUEOU PEN G 1.2 MILLION UNIT/2 ML 7/1/2015 99/99/9999 M0100049-0520-83 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PFIZERPEN 5 MILLION UNITS VIAL 7/1/2015 99/99/9999 M0100049-0530-28 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PFIZERPEN 20 MILLION UNIT VIAL 7/1/2015 99/99/9999 M0100338-1021-41 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PEN G K 1 MILLION UNIT/50 ML 7/1/2015 99/99/9999 M0100338-1023-41 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PEN G K 2 MILLION UNIT/50 ML 7/1/2015 99/99/9999 M0100338-1025-41 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PEN G K 3 MILLION UNIT/50 ML 7/1/2015 99/99/9999 M0100781-6135-95 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PENICILLIN G K 5 MILLION UNIT 7/1/2015 99/99/9999 M0100781-6136-94 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PENICILLIN GK 20 MILLION UNIT 7/1/2015 99/99/9999 M0163323-0300-20 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 8/30/2011 99/99/9999 M0163323-0309-20 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 7/1/2011 99/99/9999 M0163323-0320-50 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 4.5 GM VIAL 8/30/2011 99/99/9999 M0125021-0164-30 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 11/8/2011 99/99/9999 M0125021-0165-30 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 11/8/2011 99/99/9999 M0100409-3378-13 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 2/8/2011 99/99/9999 M0100409-3385-13 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 3.375 GM VL 2/6/2011 99/99/9999 M0100781-3110-95 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 1/1/2011 99/99/9999 M0100206-8852-16 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 4/1/2008 99/99/9999 M0100206-8852-18 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2/0.25 GM ADD-VANTAGE VL 4/1/2008 3/31/2010 M0100206-8854-16 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GRAM VIAL 4/1/2008 99/99/9999 M0100206-8854-18 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3/0.375 GM ADD-VANTAGE 4/1/2008 6/30/2008 M0100206-8855-16 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GRAM VIAL 4/1/2008 99/99/9999 M0100206-8855-18 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4/0.5 GM ADD-VANTAGE VL 4/1/2008 6/30/2008 M0100206-8859-10 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 40.5 GRAM BULK VIAL 4/1/2008 99/99/9999 M0100206-8860-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GM/50 ML GALAXY BAG 4/1/2008 99/99/9999 M0100206-8861-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GM/50 ML GALAXY 4/1/2008 99/99/9999 M0100206-8862-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 4/1/2008 99/99/9999 M0100206-2413-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 8/30/2011 99/99/9999 M0100206-2404-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 8/30/2011 8/31/2017 M0100206-2405-02 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GRAM VIAL 7/19/2010 9/30/2017 M0100206-8854-08 J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3.375 GRAM VIAL 5/29/2008 99/99/9999 M0139822-5500-03 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 1/1/2012 99/99/9999 M0100143-9868-22 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 12/30/2008 99/99/9999 M01