Self-Administered Drugs Code List 2019

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Policy Name: Self-Administered Drugs

Effective: 10/1/2019 Assigned J codes Code Brand Name Generic Name J0135 HUMIRA adalimumab J0364 APOKYN apomorphine J0593 TAKHZYRO lanadelumab-flyo J0599 HAEGARDA C-1 esterase inhibitor NOVAREL J0725 chorionic gonadotropin PREGNYL J1324 FUZEON enfuvertide ENBREL J1438 etanercept ENBREL MINI COPAXONE J1595 GLATOPA glatiramer acetate glatiramer J1628 TREMFYA guselkumab AVONEX J1826 interferon beta-1A REBIF BETASERON J1830 interferon beta-1B EXTAVIA J2170 INCRELEX mecasermin J2212 RELISTOR methylnaltrexone bromide J2354 SANDOSTATIN octreotide acetate J2355 NEUMEGA oprelvekin J2504 ADAGEN pegademase bovine GENOTROPIN HUMATROPE NORDITROPIN NUTROPIN J2941 OMNITROPE somatropin SAIZEN SEROSTIM ZORBTIVE ZOMACTON J3031 AJOVY fremanezumab-vfrm J3110 FORTEO teriparatide J7513 ZINBRYTA daclizumab AFINITOR J7527 everlimus ZORTRESS J7639 PULMOZYME dornase alfa TOBI J7682 TOBI PODHALER tobramycin nebulization solution KITABIS PAK J7685 BETHKIS tobramycin nebulization solution J8501 EMEND aprepitant J8510 MYLERAN busulfan (oral) J8515 N/A cabergoline

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J8520 XELODA capecitabine 150 mg J8521 XELODA capecitabine 500 mg J8530 N/A cyclophosphamide (oral) J8560 N/A etoposide (oral) J8565 IRESSA gefitinib J8600 ALKERAN melphalan (oral) J8610 N/A methotrexate (oral) J8650 CESAMET nabilone J8655 AKYNZEO netupitant and palonosetron J8700 TEMODAR temozolomide (oral) J8705 HYCAMTIN (oral) topotecan J9216 ACTIMMUNE Interferon gamma-1B J9218 N/A leuprolide

Code Definition S0012 Butorphanol tartrate, nasal spray, 25 mg S0014 Tacrine HCl, 10 mg S0088 Imatinib, 100 mg S0090 Sildenafil citrate, 25 mg S0091 Granisetron HCl, 1 mg S0104 Zidovudine, oral, 100 mg S0106 Bupropion HCl sustained release tablet, 150 mg, per bottle of 60 tablets S0108 Mercaptopurine, oral, 50 mg S0117 Tretinoin, topical, 5 g S0119 Ondansetron, oral, 4 mg S0122 Injection, menotropins, 75 IU S0126 Injection, follitropin alfa, 75 IU S0128 Injection, follitropin beta, 75 IU S0132 Injection, ganirelix acetate, 250 mcg S0136 Clozapine, 25 mg S0137 Didanosine (ddI), 25 mg S0138 Finasteride, 5 mg S0139 Minoxidil, 10 mg S0140 Saquinavir, 200 mg S0145 Injection, pegylated interferon alfa-2a, 180 mcg per ml S0148 Injection, pegylated interferon alfa-2B, 10 mcg S0156 Exemestane, 25 mg S0157 Becaplermin gel 0.01%, 0.5 gm S0160 Dextroamphetamine sulfate, 5 mg S0169 Calcitrol, 0.25 mcg S0170 Anastrozole, oral, 1 mg S0172 Chlorambucil, oral, 2 mg S0174 Dolasetron mesylate, oral 50 mg

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S0175 Flutamide, oral, 125 mg S0176 Hydroxyurea, oral, 500 mg S0177 Levamisole HCl, oral, 50 mg S0178 Lomustine, oral, 10 mg S0179 Megestrol acetate, oral, 20 mg S0182 Procarbazine HCl, oral, 50 mg S0183 Prochlorperazine maleate, oral, 5 mg S0187 Tamoxifen citrate, oral, 10 mg S0191 Misoprostol, oral, 200 mcg S0194 Dialysis/stress vitamin supplement, oral, 100 capsules S0197 Prenatal vitamins, 30-day supply S4990 Nicotine patches, legend S4991 Nicotine patches, nonlegend S4993 Contraceptive pills for birth control S4995 Smoking cessation gum S5000 Prescription drug, generic S5001 Prescription drug, brand name

Miscellaneous Jcodes (J3490, J3590, J8499, J8999, J9999) Code NDC Brand Name Generic Name Description 225 mg/1.5 ml J3490/3590 51759020410 AJOVY fremanezumab-vfrm syringe 55513084101 J3490/3590 55513084102 AIMOVIG erenumab-aooe 70 mg/ml pen 55513084301 aztreonam nebulization J3490/3590 61958090101 CAYSTON 75 MG/vial solution J3490/3590 44087122501 CETROTIDE cetrorelix acetate 0.25 MG kit 00078063997 150 MG/ML J3490/3590 COSENTYX seckinumab

00078063998 syringe 00078063941 COSENTYX J3490/3590 seckinumab 150 MG/ML pen

00078063968 SENSOREADY PEN J3490/3590 00024591401 DUPIXENT dupilimab 300 MG syringe J3490/3590 00024591801 DUPIXENT dupilimab 200 MG syringe J3490/3590 EGRIFTA tesamorelin 1 MG/vial 62064001160 00002143601 J3490/3590 EMGALITY galcanezumab-gnlm 120 mg pen 00002143611 00002237701 00002237711 J3490/3590 EMGALITY galcanezumab-gnlm 120 mg syringe 00002311501 00002311509 J3490/3590 FOLLISTIM AQ follitropin beta 300/0.42ML 00052031301 600/0.78ML J3490/3590 00052031601 FOLLISTIM AQ follitropin beta solution 900/1.17ML J3490/3590 FOLLISTIM AQ follitropin beta 00052032601 solution

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00052030151 GANIRELIX 250MCG/0.5 ML J3490/3590 ganirelix acetate

55566100001 ACETATE syringe J3490/3590 44087903001 GONAL-F follitropin alfa 450 UNIT vial J3490/3590 44087907001 GONAL-F follitropin alfa 1050 UNIT vial 44087900501 J3490/3590 GONAL-F RFF follitropin alfa 75 UNIT vial

44087900506 GONAL-F RFF J3490/3590 44087111501 follitropin alfa 300/0.5ML pen REDI-JECT GONAL-F RFF J3490/3590 44087111601 follitropin alfa 450/0.75ML pen REDI-JECT GONAL-F RFF J3490/3590 44087111701 follitropin alfa 900/1.5 ML pen REDI-JECT J3490/3590 00024591001 KEVZARA sarilumab 200mg syringe J3490/3590 00024590801 KEVZARA sarilumab 150mg syringe J3490/3590 00024592201 KEVZARA sarilumab 200mg pen J3490/3590 00024592001 KEVZARA sarilumab 150mg pen 66658023407 100MG/0.67 ML J3490/3590 KINERET anakinra 66658023428 syringe 70688050201 200 MG/ML J3490/3590 KYNAMRO mipomercin 70688050202 syringe leuprolide acetate and 3.75MG-5MG J3490/3590 00074105205 LUPANETA PACK norethindrone acetate KIT leuprolide acetate and J3490/3590 00074105305 LUPANETA PACK 11.25-5 MG KIT norethindrone acetate 55566750101 J3490/3590 MENOPUR menotropins 75 UNIT vial

55566750102 J3490/3590 76431021001 MYALEPT metreleptin 11.3MG vial 68875020201 25 MCG J3490/3590 NATPARA parathyroid hormone cartridge 68875020202 68875020301 50 MCG J3490/3590 NATPARA parathyroid hormone 68875020302 cartridge 68875020401 75 MCG J3490/3590 NATPARA parathyroid hormone cartridge 68875020402 68875020501 100 MCG J3490/3590 NATPARA parathyroid hormone 68875020502 cartridge 250MCG/0.5 J3490/3590 44087115001 OVIDREL choriogonadotropin alfa syringe 180MCG/0.5 ML J3490/3590 00004035730 PEGASYS peginterferon alfa-2a syringe J3490/3590 00004035009 PEGASYS peginterferon alfa-2a 180MCG/ML vial 00004036009 PEGASYS 135MCG/0.5 ML J3490/3590 peginterferon alfa-2a 00004036030 PROCLICK BOX syringe 00004036509 PEGASYS 180MCG/0.5 ML J3490/3590 peginterferon alfa-2a

00004036530 PROCLICK syringe 50 MCG/0.5 ML J3490/3590 PEGINTRON peginterferon alfa-2b 00085435301 kit 120MCG/0.5 ML J3490/3590 PEGINTRON peginterferon alfa-2b 00085435501 kit 64406001501 125MCG/0.5 ML J3490/3590 PLEGRIDY peginterferon beta-1a 64406001502 syringe PLEGRIDY 63-94 MCG/0.5 J3490/3590 64406001601 peginterferon beta-1a (STARTER PACK) ML syringe 64406001101 J3490/3590 PLEGRIDY PEN peginterferon beta-1a 125MCG/0.5 ML

64406001102

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PLEGRIDY PEN 63-94 MCG/0.5 J3490/3590 64406001201 peginterferon beta-1a (STARTER PACK) ML 00024590101 J3490/3590 00024590102 PRALUENT alirocumab 75 MG/1ML kit 72733590102 00024590201 J3490/3590 00024590202 PRALUENT alirocumab 150MG/1ML kit 72733590202 1.1GRAM/ML J3490/3590 75987050006 RAVICTI glycerol phenylbutyrate bottle 55512075001 140MG/ML J3490/3590 REPATHA evolocumab 72511075001 syringe 55513077001 420MG/3.5 ML J3490/3590 REPATHA evolocumab 72511077001 cartridge 55513076001 55513076002 140MG/1ML J3490/3590 REPATHA evolocumab 72511076001 autoinjector 72511076002 00187000400 210mg/1.5ml J3490/3590 SILIQ brodalumab 00187000402 syringe 00074204202 J3490/3590 SKYRIZI risankizumab-rzaa 150 MG 00074204271 J3490/3590 00009716601 SOMAVERT pegvisomant 10 MG J3490/3590 00009716801 SOMAVERT pegvisomant 15 MG J3490/3590 00009718801 SOMAVERT pegvisomant 20 MG J3490/3590 00009719901 SOMAVERT pegvisomant 25 MG J3490/3590 00009720001 SOMAVERT pegvisomant 30 MG J3490/3590 50458002802 SPRAVATO esketamine 56 MG J3490/3590 50458002803 SPRAVATO esketamine 84 MG 00085138801 peginterferon alfa-2b J3490/3590 SYLATRON 200 MCG kit 00085434701 (oncology) 00085128702 peginterferon alfa-2b J3490/3590 SYLATRON 300 MCG kit 00085434801 (oncology) 00085434901 peginterferon alfa-2b J3490/3590 SYLATRON 600 MCG kit 00085131201 (oncology) J3490/3590 47783064401 TAKHZYRO lanadelumab-flyo 300 MG/2 ML 00002144501 00002144509 80MG/ML J3490/3590 TALTZ ixekizumab 00002144511 autoinjector 00002144527 00002772401 80MG/ML J3490/3590 TALTZ ixekizumab 00002772411 syringe 70539000101 3120mcg/1.56ml J3490/3590 TYMLOS abaloparatide 70539000102 pen injector J8499 Prescription drug, oral, nonchemotherapeutic, NOS J8999 Misc. Oral Oncology

Note: Unclassified codes apply to all medications defined as Self-Administered Drugs herein. Examples are included and limited at the NDC level.

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