Medical Injection Drug Program Effective 10/03/2011

Generic Name HCPCS Brand Name (billing code description) Code*

Actemra tocilizumab J3262 Actimmune interferon gamma-1b J9216 Aldurazyme laronidase J1931 Amevive alefacept J0215 Avonex interferon beta-1a J1826 & Q3025

Benlysta belimumab Q2044 Betaseron interferon beta-1b J1830 Boniva ibandronite sodium J1740 Botox botulinum toxin type A J0585 Cerezyme imiglucerase J1786 Cimzia certolizumab pegol J0718 Copaxone glatiramer acetate J1595 Dysport abobotulinumtoxia A J0586 Elaprase idursulfase J1743 Eligard leuprolide acetate (implant) J9217 Enbrel etanercept J1438 Fabrazyme agalsidase beta J0180 Forteo teriparatide J3110 Euflexxa hyaluronate sodium injection J7323 Extavia interferon beta-1b J1830 Firmagon degarelix J9155 Growth Hormones (Genotropin, Humatrope, Norditropin, Nutropin, Saizen, J2941 Serostim, Tev-Tropin, Zorbtive), Omnitrope H.P. Acthar repository corticotrophin J0800 Hyalgan sodium hyaluronate J7321 Krystexxa pegloticase J3490 Lioresal Inj for Intrathecal baclofen J0476 Lioresal Injection baclofen J0475 Lucentis ranibizumab injection J2778 Lumizyme alglucosidase alfa J0220 Lupron Depot (3.75mg) incd peds leuprolide acetate J1950 Lupron Depot (7.5mg) incd peds leuprolide acetate J9217 Macugen pegaptanib sodium J2503 Makena hydroxyprogesterone Q2042 Myobloc botulinum toxin type B J0587 Myozyme alglucosidase alfa J0220 Orencia abatacept J0129 Orthovisc high molecular weight hyaluronan J7324 Prialt ziconotide intrathecal J2278 Prolia denosumab J3490 Rebif interferon beta-1a Q3026 Reclast zoledronic acid J3488 Remicade infliximab J1745 RiaSTAP fibrinogen concentrate [human] J1680 Risperdal Consta risperidone J2794 Simponi golimumab J3590 Stelara ustekinumab J3357

Effective 10/03/2011 1 of 2 Medical Injection Drug Program Effective 10/03/2011

Generic Name HCPCS Brand Name (billing code description) Code*

Supartz sodium hyaluronate J7321 Supprelin LA histrelin acetate J9226 Synagis palivizumab 90378 Synvisc (incl Synvisc One) hylan GF 20 J7325 TheraCys BCG (intravesical) J9031 Thyrogen thyrotropin alfa J3240 TICE BCG BCG (intravesical) J9031 Trelstar triptorelin pamoate J3315 Tysabri natalizumab J2323 Vantas histrelin implant J9225 Viadur leuprolide acetate implant J9219 Visudyne verteporfin J3396 VPRIV veraglucerase J3385 Xeomin incobotulinumtoxin A Q2040 Xolair omalizumab J2357 Zoladex goserelin acetate implant J9202 FACTOR PRODUCTS Alphanate antihemophilic factor/von Willebrand factor complex J7186 [human] Autoplex T, Feiba VH (anti-inhibitor coagulant complex) J7198 Factor VIIa-NovoSeven (coagulation factor, recombinant) J7189 Factor VIII (antihemophilic factor, human) J7190 Factor VIII (antihemophilic factor (porcine) J7191 Factor VIII (antihemophilic factor, recombinant) J7192 Factor IX (antihemophilic factor, purified, non-recombinant) J7193 Factor IX complex J7194 Factor IX (antihemophilic factor, recombinant) J7195 Humate-P antihemophilic factor/von Willebrand factor complex J7187 [human] WILATE von Willebrand factor/coagulation factor VIII complex J7184 [human] Xyntha (antihemophilic factor, recombinant) J7185 IVIG Hizentra immune globulin [human] J1559 IVIG [immune globulin] (lyophilized and (Carimune NF, Gammagard S/D, Gammar-P I.V., Iveegam J1566 non-lyophilized) EN, Polygam S/D, Panglobulin NF) IVIG [immune globulin] Flebogamma only J1572 IVIG [immune globulin] Gamunex only J1561 IVIG [immune globulin] Octagam only J1568 IVIG [immune globulin] Gammagard only J1569 IVIG [immune globulin] immune globulin [human] 90283 Privigen immune globulin [human] J1459 Vivaglobin immune globulin subcutaneous J1562 & 90284

Effective 10/03/2011 2 of 2