CPT / HCPCS Code Drug Description Approximate Cost Share

Home , Alatrofloxacin, Arbutamine, Aurothioglucose, Bromide, Caffeine citrate, Dornase alfa

The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

Legend $0 = no cost share $ = $100 and under $$ = over $100 to $250 $$$ = over $250 to $500 $$$$ = over $500 to $1000 $$$$$ = over $1000 1 = Please call HMSA Customer Service 1-800-776-4672 for cost share information. 2 = The cost share for this drug is dependent upon the diagnosis. Please call HMSA Customer Service at 1-800-772-4672 for more information. 3 = Cost share information for these drugs is dependent upon the dose prescribed. Please call HMSA Customer Service at 1- 800-772-4672 for more information.

CPT / HCPCS approximate Code Drug Description cost share J0129 Abatacept Injection $$$$ J0130 Abciximab Injection 3 J0131 Acetaminophen Injection $ J0132 Acetylcysteine Injection $ J0133 Acyclovir Injection $ J0135 Adalimumab Injection $$$$ J0153 Adenosine Inj 1Mg $ J0171 Adrenalin Epinephrine Inject $ J0178 Aflibercept Injection $$$ J0180 Agalsidase Beta Injection 3 J0200 Alatrofloxacin Mesylate 3 J0205 Alglucerase Injection 3 J0207 Amifostine 3 J0210 Methyldopate Hcl Injection 3 J0215 Alefacept 3 J0220 Alglucosidase Alfa Injection 3 J0221 Lumizyme Injection 3 J0256 Alpha 1 Proteinase Inhibitor $$$$$ J0257 Glassia Injection $$$$ J0270 Alprostadil For Injection $ J0275 Alprostadil Urethral Suppos 1 J0278 Amikacin Sulfate Injection $ J0280 Aminophyllin 250 Mg Inj $ J0282 Amiodarone Hcl $ J0285 Amphotericin B $ J0287 Amphotericin B Lipid Complex 3 J0288 Ampho B Cholesteryl Sulfate 3 J0289 Amphotericin B Liposome Inj $ J0290 Ampicillin 500 Mg Inj 3 J0295 Ampicillin Sodium Per 1.5 Gm $ J0300 Amobarbital 125 Mg Inj $$$ J0330 Succinycholine Chloride Inj $ J0348 Anidulafungin Injection $ J0350 Injection Anistreplase 30 U 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J0360 Hydralazine Hcl Injection $ J0364 Apomorphine Hydrochloride 3 J0365 Aprotonin, 10,000 Kiu 3 J0380 Inj Metaraminol Bitartrate 3 J0390 Chloroquine Injection 3 J0395 Arbutamine Hcl Injection 3 J0400 Aripiprazole Injection 3 J0401 Inj Aripiprazole Ext Rel 1Mg $$ J0456 Azithromycin $ J0461 Atropine Sulfate Injection $ J0470 Dimecaprol Injection $ J0475 Baclofen 10 Mg Injection $$ J0476 Baclofen Intrathecal Trial 3 J0480 Basiliximab $$$$ J0485 Belatacept Injection 3 J0490 Belimumab Injection $$$$ J0500 Dicyclomine Injection $ J0515 Inj Benztropine Mesylate $ J0520 Bethanechol Chloride Inject 3 J0558 Peng Benzathine/Procaine Inj $ J0561 Penicillin G Benzathine Inj $ J0583 Bivalirudin $$$ J0585 Injection,Onabotulinumtoxina $ J0586 Abobotulinumtoxina $$$ J0587 Inj, Rimabotulinumtoxinb $$ J0588 Incobotulinumtoxin A $ J0592 Buprenorphine Hydrochloride $$$ J0594 Busulfan Injection $$$$$ J0595 Butorphanol Tartrate 1 Mg 3 J0597 C-1 Esterase, Berinert 3 J0598 C-1 Esterase, Cinryze 3 J0600 Edetate Calcium Disodium Inj 3 J0610 Calcium Gluconate Injection $ J0620 Calcium Glycer & Lact/10 Ml 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J0630 Calcitonin Salmon Injection 3 J0636 Inj Calcitriol Per 0.1 Mcg $ J0637 Caspofungin Acetate $ J0638 Canakinumab Injection 3 J0640 Leucovorin Calcium Injection $ J0641 Levoleucovorin Injection 3 J0670 Inj Mepivacaine Hcl/10 Ml $ J0690 Cefazolin Sodium Injection $ J0692 Cefepime Hcl For Injection $ J0694 Cefoxitin Sodium Injection 3 J0696 Ceftriaxone Sodium Injection $ J0697 Sterile Cefuroxime Injection $ J0698 Cefotaxime Sodium Injection $ J0702 Betamethasone Acet&Sod Phosp $ J0706 Caffeine Citrate Injection 3 J0710 Cephapirin Sodium Injection $ J0712 Ceftaroline Fosamil Inj $ J0713 Inj Ceftazidime Per 500 Mg $ J0715 Ceftizoxime Sodium / 500 Mg $ J0717 Certolizumab Pegol Inj 1Mg $$$$ J0720 Chloramphenicol Sodium Injec 3 J0725 Chorionic Gonadotropin/1000U $ J0735 Clonidine Hydrochloride 3 J0740 Cidofovir Injection $$ J0743 Cilastatin Sodium Injection $ J0744 Ciprofloxacin Iv $ J0745 Inj Codeine Phosphate /30 Mg 3 J0760 Colchicine Injection 1 J0770 Colistimethate Sodium Inj $$ J0775 Collagenase, Clost Hist Inj $$$ J0780 Prochlorperazine Injection $ J0795 Corticorelin Ovine Triflutal 3 J0800 Corticotropin Injection 3 J0833 Cosyntropin Injection Nos $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J0834 Cosyntropin Cortrosyn Inj $ J0840 Crotalidae Poly Immune Fab 3 J0850 Cytomegalovirus Imm Iv /Vial $$$ J0878 Daptomycin Injection $ J0881 Darbepoetin Alfa, Non-Esrd $$ J0882 Darbepoetin Alfa, Esrd Use $ J0885 Epoetin Alfa, Non-Esrd $ J0886 Epoetin Alfa 1000 Units Esrd 1 J0887 Epoetin Beta Esrd Use $ J0888 Epoetin Beta Non Esrd 3 J0890 Peginesatide Injection 3 J0894 Decitabine Injection $$ J0895 Deferoxamine Mesylate Inj $ J0897 Denosumab Injection $$$ J0945 Brompheniramine Maleate Inj 3 J1000 Depo-Estradiol Cypionate Inj $ J1020 Methylprednisolone 20 Mg Inj $ J1030 Methylprednisolone 40 Mg Inj $ J1040 Methylprednisolone 80 Mg Inj $ J1050 Medroxyprogesterone Acetate 2 J1071 Inj Testosterone Cypionate $ J1094 Inj Dexamethasone Acetate $ J1100 Dexamethasone Sodium Phos $ J1110 Inj Dihydroergotamine Mesylt $ J1120 Acetazolamid Sodium Injectio $ J1160 Digoxin Injection $ J1162 Digoxin Immune Fab (Ovine) 3 J1165 Phenytoin Sodium Injection 3 J1170 Hydromorphone Injection $ J1180 Dyphylline Injection 3 J1190 Dexrazoxane Hcl Injection $$$ J1200 Diphenhydramine Hcl Injectio $ J1205 Chlorothiazide Sodium Inj 3 J1212 Dimethyl Sulfoxide 50% 50 Ml $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J1230 Methadone Injection $ J1240 Dimenhydrinate Injection $ J1245 Dipyridamole Injection 3 J1250 Inj Dobutamine Hcl/250 Mg $ J1260 Dolasetron Mesylate $ J1265 Dopamine Injection $ J1267 Doripenem Injection 3 J1270 Injection, Doxercalciferol $ J1290 Ecallantide Injection 3 J1300 Eculizumab Injection $$$$$ J1320 Amitriptyline Injection 3 J1325 Epoprostenol Injection 3 J1327 Eptifibatide Injection $$$$ J1330 Ergonovine Maleate Injection 3 J1335 Ertapenem Injection $ J1364 Erythro Lactobionate /500 Mg 3 J1380 Estradiol Valerate 10 Mg Inj $ J1410 Inj Estrogen Conjugate 25 Mg 3 J1430 Ethanolamine Oleate 100 Mg 3 J1435 Injection Estrone Per 1 Mg 3 J1436 Etidronate Disodium Inj 3 J1438 Etanercept Injection $$$$ J1439 Inj Ferric Carboxymaltos 1Mg $$ J1442 Inj Filgrastim Excl Biosimil $$ J1446 Inj, Tbo-Filgrastim, 5 Mcg 1 J1450 Fluconazole $ J1451 Fomepizole, 15 Mg 3 J1452 Intraocular Fomivirsen Na 3 J1453 Fosaprepitant Injection $ J1455 Foscarnet Sodium Injection $$ J1457 Gallium Nitrate Injection 3 J1458 Galsulfase Injection $$$$$ J1459 Inj Ivig Privigen 500 Mg $$$$ J1460 Gamma Globulin 1 Cc Inj $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J1556 Inj, Imm Glob Bivigam, 500Mg 3 J1557 Gammaplex Injection 3 J1559 Hizentra Injection $$ J1560 Gamma Globulin Gt 10 Cc Inj 3 J1561 Gamunex-C/Gammaked $$$$ J1562 Vivaglobin, Inj 3 J1566 Immune Globulin, Powder $$$$ J1568 Octagam Injection $$$$$ J1569 Gammagard Liquid Injection $$$$$ J1570 Ganciclovir Sodium Injection $$ J1571 Hepagam B Im Injection $$ J1572 Flebogamma Injection $$$$ J1573 Hepagam B Intravenous, Inj 3 J1580 Garamycin Gentamicin Inj $ J1590 Gatifloxacin Injection 1 J1595 Injection Glatiramer Acetate $$$ J1600 Gold Sodium Thiomaleate Inj 3 J1602 Golimumab For Iv Use 1Mg 3 J1610 Glucagon Hydrochloride/1 Mg $ J1620 Gonadorelin Hydroch/ 100 Mcg 3 J1626 Granisetron Hcl Injection $ J1630 Haloperidol Injection $ J1631 Haloperidol Decanoate Inj $ J1640 Hemin, 1 Mg 3 J1642 Inj Heparin Sodium Per 10 U $ J1644 Inj Heparin Sodium Per 1000U $ J1645 Dalteparin Sodium 3 J1650 Inj Enoxaparin Sodium $ J1652 Fondaparinux Sodium $ J1655 Tinzaparin Sodium Injection 3 J1670 Tetanus Immune Globulin Inj $ J1700 Hydrocortisone Acetate Inj 3 J1710 Hydrocortisone Sodium Ph Inj $ J1720 Hydrocortisone Sodium Succ I $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J1725 Hydroxyprogesterone Caproate $$$$ J1730 Diazoxide Injection 3 J1740 Ibandronate Sodium Injection $ J1742 Ibutilide Fumarate Injection 3 J1743 Idursulfase Injection 3 J1745 Infliximab Not Biosimil 10Mg $$$$ J1750 Inj Iron Dextran $ J1756 Iron Sucrose Injection $ J1786 Imuglucerase Injection 3 J1790 Droperidol Injection $ J1800 Propranolol Injection $ J1810 Droperidol/Fentanyl Inj $ J1815 Insulin Injection $ J1817 Insulin For Insulin Pump Use 3 J1830 Interferon Beta-1B / .25 Mg $$$$$ J1835 Itraconazole Injection 3 J1840 Kanamycin Sulfate 500 Mg Inj 3 J1850 Kanamycin Sulfate 75 Mg Inj 3 J1885 Ketorolac Tromethamine Inj $ J1890 Cephalothin Sodium Injection 3 J1930 Lanreotide Injection $$$$$ J1931 Laronidase Injection 3 J1940 Furosemide Injection $ J1945 Lepirudin 3 J1950 Leuprolide Acetate /3.75 Mg $$ J1953 Levetiracetam Injection 3 J1955 Inj Levocarnitine Per 1 Gm 3 J1956 Levofloxacin Injection 3 J1960 Levorphanol Tartrate Inj 3 J1980 Hyoscyamine Sulfate Inj 3 J1990 Chlordiazepoxide Injection 3 J2001 Lidocaine Injection $ J2010 Lincomycin Injection $ J2020 Linezolid Injection $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J2060 Lorazepam Injection $ J2150 Mannitol Injection $ J2175 Meperidine Hydrochl /100 Mg $ J2180 Meperidine/Promethazine Inj $ J2185 Meropenem $ J2210 Methylergonovin Maleate Inj 3 J2248 Micafungin Sodium Injection $ J2250 Inj Midazolam Hydrochloride $ J2260 Inj Milrinone Lactate / 5 Mg 3 J2270 Morphine Sulfate Injection $ J2274 In Morphine Preservativ Free $ J2278 Ziconotide Injection $$ J2280 Inj, Moxifloxacin 100 Mg $ J2300 Inj Nalbuphine Hydrochloride $ J2310 Inj Naloxone Hydrochloride $ J2315 Naltrexone, Depot Form $$ J2320 Nandrolone Decanoate 50 Mg 3 J2323 Natalizumab Injection $$$$$ J2325 Nesiritide Injection 3 J2353 Octreotide Injection, Depot $$$$ J2354 Octreotide Inj, Non-Depot $ J2355 Oprelvekin Injection 3 J2357 Omalizumab Injection $$$ J2358 Olanzapine Long-Acting Inj 3 J2360 Orphenadrine Injection $ J2370 Phenylephrine Hcl Injection $ J2400 Chloroprocaine Hcl Injection 3 J2405 Ondansetron Hcl Injection $ J2410 Oxymorphone Hcl Injection 3 J2425 Palifermin Injection 3 J2426 Paliperidone Palmitate Inj $$ J2430 Pamidronate Disodium /30 Mg $ J2440 Papaverin Hcl Injection 3 J2460 Oxytetracycline Injection 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J2469 Palonosetron Hcl $ J2501 Paricalcitol $ J2503 Pegaptanib Sodium Injection 3 J2504 Pegademase Bovine, 25 Iu 3 J2505 Injection, Pegfilgrastim 6Mg $$$$ J2507 Pegloticase Injection 3 J2510 Penicillin G Procaine Inj 3 J2513 Pentastarch 10% Solution 3 J2515 Pentobarbital Sodium Inj 3 J2540 Penicillin G Potassium Inj $ J2543 Piperacillin/Tazobactam $ J2545 Pentamidine Non-Comp Unit 3 J2550 Promethazine Hcl Injection $ J2560 Phenobarbital Sodium Inj 3 J2562 Plerixafor Injection $$$$$ J2590 Oxytocin Injection $ J2597 Inj Desmopressin Acetate $ J2650 Prednisolone Acetate Inj 3 J2670 Totazoline Hcl Injection 3 J2675 Inj Progesterone Per 50 Mg $ J2680 Fluphenazine Decanoate 25 Mg $ J2690 Procainamide Hcl Injection $ J2700 Oxacillin Sodium Injeciton $$ J2704 Inj, Propofol, 10 Mg $ J2710 Neostigmine Methylslfte Inj $ J2720 Inj Protamine Sulfate/10 Mg 3 J2724 Protein C Concentrate 3 J2725 Inj Protirelin Per 250 Mcg 3 J2730 Pralidoxime Chloride Inj $ J2760 Phentolaine Mesylate Inj 3 J2765 Metoclopramide Hcl Injection $ J2770 Quinupristin/Dalfopristin 3 J2778 Ranibizumab Injection $$$ J2780 Ranitidine Hydrochloride Inj $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J2783 Rasburicase 3 J2785 Regadenoson Injection $ J2788 Rho D Immune Globulin 50 Mcg $ J2790 Rho D Immune Globulin Inj $ J2791 Rhophylac Injection 3 J2792 Rho(D) Immune Globulin H, Sd 3 J2794 Risperidone, Long Acting $$ J2795 Ropivacaine Hcl Injection $ J2796 Romiplostim Injection $$$ J2800 Methocarbamol Injection 3 J2805 Sincalide Injection $ J2810 Inj Theophylline Per 40 Mg 3 J2820 Sargramostim Injection $ J2850 Inj Secretin Synthetic Human 3 J2910 Aurothioglucose Injeciton 3 J2916 Na Ferric Gluconate Complex $ J2920 Methylprednisolone Injection $ J2930 Methylprednisolone Injection $ J2940 Somatrem Injection 3 J2941 Somatropin Injection $$ J2950 Promazine Hcl Injection $ J2993 Reteplase Injection 3 J2995 Inj Streptokinase /250000 Iu 3 J2997 Alteplase Recombinant $ J3000 Streptomycin Injection 3 J3010 Fentanyl Citrate Injeciton $ J3030 Sumatriptan Succinate / 6 Mg $ J3060 Inj, Taliglucerace Alfa 10 U 3 J3070 Pentazocine Injection 3 J3095 Telavancin Injection $ J3101 Tenecteplase Injection 3 J3105 Terbutaline Sulfate Inj $ J3110 Teriparatide Injection 3 J3121 Inj Testostero Enanthate 1Mg $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J3230 Chlorpromazine Hcl Injection 3 J3240 Thyrotropin Injection $$$ J3243 Tigecycline Injection $ J3246 Tirofiban Hcl 3 J3250 Trimethobenzamide Hcl Inj $ J3260 Tobramycin Sulfate Injection $ J3262 Tocilizumab Injection $$$ J3265 Injection Torsemide 10 Mg/Ml 3 J3280 Thiethylperazine Maleate Inj 3 J3285 Treprostinil Injection 3 J3300 Triamcinolone A Inj Prs-Free $ J3301 Triamcinolone Acet Inj Nos $ J3302 Triamcinolone Diacetate Inj $ J3303 Triamcinolone Hexacetonl Inj $ J3305 Inj Trimetrexate Glucoronate 3 J3310 Perphenazine Injeciton 3 J3315 Triptorelin Pamoate 3 J3320 Spectinomycn Di-Hcl Inj 3 J3350 Urea Injection 3 J3355 Urofollitropin, 75 Iu 3 J3357 Ustekinumab Sub Cu Inj, 1 Mg $$$$$ J3360 Diazepam Injection $ J3364 Urokinase 5000 Iu Injection 3 J3365 Urokinase 250,000 Iu Inj 3 J3370 Vancomycin Hcl Injection $ J3385 Velaglucerase Alfa 3 J3396 Verteporfin Injection 3 J3400 Triflupromazine Hcl Inj 3 J3410 Hydroxyzine Hcl Injection $ J3411 Thiamine Hcl 100 Mg $ J3415 Pyridoxine Hcl 100 Mg $ J3420 Vitamin B12 Injection $ J3430 Vitamin K Phytonadione Inj $ J3465 Injection, Voriconazole 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J3470 Hyaluronidase Injection $ J3471 Ovine, Up To 999 Usp Units 3 J3472 Ovine, 1000 Usp Units 3 J3473 Hyaluronidase Recombinant $ J3475 Inj Magnesium Sulfate $ J3480 Inj Potassium Chloride $ J3485 Zidovudine 3 J3486 Ziprasidone Mesylate $ J3489 Zoledronic Acid 1Mg $ J3520 Edetate Disodium Per 150 Mg 3 J7030 Normal Saline Solution Infus 1 J7040 Normal Saline Solution Infus 1 J7042 5% Dextrose/Normal Saline 1 J7050 Normal Saline Solution Infus 1 J7060 5% Dextrose/Water 1 J7070 D5W Infusion 1 J7100 Dextran 40 Infusion 1 J7110 Dextran 75 Infusion 1 J7120 Ringers Lactate Infusion 1 J7131 Hypertonic Saline Sol 1 J7300 Intraut Copper Contraceptive 1 J7301 Skyla, 13.5 Mg 0 J7302 Levonorgestrel Iu Contracept 1 J7302 Levonorgestrel Iu Contracept 1 J7307 Etonogestrel Implant System 0 J7308 Aminolevulinic Acid Hcl Top $ J7309 Methyl Aminolevulinate, Top 3 J7310 Ganciclovir Long Act Implant 3 J7311 Fluocinolone Acetonide Implt 3 J7312 Dexamethasone Intra Implant $$$ J7316 Inj, Ocriplasmin, 0.125 Mg $$$$ J7321 Hyalgan/Supartz Inj Per Dose $ J7323 Euflexxa Inj Per Dose $ J7324 Orthovisc Inj Per Dose $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J7325 Synvisc Or Synvisc-One $ J7326 Gel-One $ J7327 Monovisc Inj Per Dose $$ J7330 Cultured Chondrocytes Implnt 1 J7336 Capsaicin 8% Patch 1 J7500 Azathioprine Oral 50Mg 1 J7501 Azathioprine Parenteral 3 J7502 Cyclosporine Oral 100 Mg 1 J7504 Lymphocyte Immune Globulin $$$$$ J7505 Monoclonal Antibodies 3 J7506 Prednisone Oral 1 J7507 Tacrolimus Imme Rel Oral 1Mg 1 J7508 Tacrol Astagraf Ex Rel Oral 1 J7509 Methylprednisolone Oral 1 J7510 Prednisolone Oral Per 5 Mg 1 J7511 Antithymocyte Globuln Rabbit 3 J7513 Daclizumab, Parenteral 3 J7515 Cyclosporine Oral 25 Mg 1 J7516 Cyclosporin Parenteral 250Mg 3 J7517 Mycophenolate Mofetil Oral 1 J7518 Mycophenolic Acid 1 J7520 Sirolimus, Oral 1 J7525 Tacrolimus Injection $ J7527 Oral Everolimus 1 J7605 Arformoterol Non-Comp Unit $ J7606 Formoterol Fumarate, Inh 3 J7608 Acetylcysteine Non-Comp Unit 3 J7611 Albuterol Non-Comp Con $ J7612 Levalbuterol Non-Comp Con $ J7613 Albuterol Non-Comp Unit $ J7614 Levalbuterol Non-Comp Unit $ J7620 Albuterol Ipratrop Non-Comp $ J7622 Beclomethasone Comp Unit 3 J7624 Betamethasone Comp Unit 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J7626 Budesonide Non-Comp Unit $ J7631 Cromolyn Sodium Noncomp Unit 3 J7633 Budesonide Non-Comp Con $ J7635 Atropine Comp Con 3 J7636 Atropine Comp Unit 3 J7637 Dexamethasone Comp Con 3 J7638 Dexamethasone Comp Unit 3 J7639 Dornase Alfa Non-Comp Unit 3 J7641 Flunisolide Comp Unit 3 J7642 Glycopyrrolate Comp Con 3 J7643 Glycopyrrolate Comp Unit $ J7644 Ipratropium Bromide Non-Comp $ J7649 Isoetharine Non-Comp Unit 3 J7658 Isoproterenol Non-Comp Con 3 J7659 Isoproterenol Non-Comp Unit 3 J7665 Mannitol For Inhaler 3 J7668 Metaproterenol Non-Comp Con 3 J7669 Metaproterenol Non-Comp Unit 3 J7674 Methacholine Chloride, Neb $ J7680 Terbutaline Sulf Comp Con 3 J7681 Terbutaline Sulf Comp Unit 3 J7682 Tobramycin Non-Comp Unit 3 J7683 Triamcinolone Comp Con 3 J7684 Triamcinolone Comp Unit 3 J7686 Treprostinil, Non-Comp Unit 3 J8501 Oral Aprepitant 0 J8510 Oral Busulfan 0 J8515 Cabergoline, Oral 0.25Mg 0 J8520 Capecitabine, Oral, 150 Mg 0 J8521 Capecitabine, Oral, 500 Mg 0 J8530 Cyclophosphamide Oral 25 Mg 0 J8540 Oral Dexamethasone 0 J8560 Etoposide Oral 50 Mg 0 J8562 Oral Fludarabine Phosphate 0 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J8600 Melphalan Oral 2 Mg 0 J8610 Methotrexate Oral 2.5 Mg 0 J8700 Temozolomide 0 J8705 Topotecan Oral 0 J9000 Doxorubicin Hcl Injection $ J9010 Alemtuzumab Injection 1 J9015 Aldesleukin Injection 3 J9017 Arsenic Trioxide Injection $$ J9019 Erwinaze Injection $$$$$ J9020 Asparaginase, Nos 3 J9025 Azacitidine Injection $$ J9027 Clofarabine Injection 3 J9031 Bcg Live Intravesical Vac $ J9033 Inj., Treanda 1 Mg $$$$ J9035 Bevacizumab Injection $$$$ J9040 Bleomycin Sulfate Injection $ J9041 Bortezomib Injection $$$ J9042 Brentuximab Vedotin Inj $$$$$ J9043 Cabazitaxel Injection $$$$$ J9045 Carboplatin Injection $ J9047 Injection, Carfilzomib, 1 Mg $$$ J9050 Carmustine Injection 3 J9055 Cetuximab Injection $$$$ J9060 Cisplatin 10 Mg Injection $ J9065 Inj Cladribine Per 1 Mg $ J9070 Cyclophosphamide 100 Mg Inj $$ J9098 Cytarabine Liposome Inj 3 J9100 Cytarabine Hcl 100 Mg Inj $ J9120 Dactinomycin Injection $$$$$ J9130 Dacarbazine 100 Mg Inj $ J9150 Daunorubicin Injection $$ J9151 Daunorubicin Citrate Inj 3 J9155 Degarelix Injection $ J9160 Denileukin Diftitox Inj 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J9165 Diethylstilbestrol Injection 3 J9171 Docetaxel Injection $ J9175 Elliotts B Solution Per Ml $ J9178 Inj, Epirubicin Hcl, 2 Mg $ J9179 Eribulin Mesylate Injection $$$$ J9181 Etoposide Injection $ J9185 Fludarabine Phosphate Inj $ J9190 Fluorouracil Injection $ J9200 Floxuridine Injection 3 J9201 Gemcitabine Hcl Injection $ J9202 Goserelin Acetate Implant $ J9206 Irinotecan Injection $ J9207 Ixabepilone Injection $$$$$ J9208 Ifosfamide Injection $$ J9209 Mesna Injection $ J9211 Idarubicin Hcl Injection 3 J9212 Interferon Alfacon-1 Inj 3 J9213 Interferon Alfa-2A Inj 3 J9214 Interferon Alfa-2B Inj $$ J9215 Interferon Alfa-N3 Inj 3 J9216 Interferon Gamma 1-B Inj 3 J9217 Leuprolide Acetate Suspnsion $$ J9218 Leuprolide Acetate Injeciton $ J9219 Leuprolide Acetate Implant 1 J9225 Vantas Implant 1 J9226 Supprelin La Implant 1 J9228 Ipilimumab Injection $$$$$ J9230 Mechlorethamine Hcl Inj 3 J9245 Inj Melphalan Hydrochl 50 Mg 3 J9250 Methotrexate Sodium Inj $ J9260 Methotrexate Sodium Inj $ J9261 Nelarabine Injection $$$$ J9263 Oxaliplatin $ J9264 Paclitaxel Protein Bound $$$$ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J9266 Pegaspargase Injection $$$$$ J9267 Paclitaxel Injection $ J9268 Pentostatin Injection 3 J9270 Plicamycin (Mithramycin) Inj 3 J9280 Mitomycin Injection 3 J9293 Mitoxantrone Hydrochl / 5 Mg $ J9300 Gemtuzumab Ozogamicin Inj 3 J9301 Obinutuzumab Inj $$$$$ J9302 Ofatumumab Injection 3 J9303 Panitumumab Injection $$$$$ J9305 Pemetrexed Injection $$$$$ J9306 Injection, Pertuzumab, 1 Mg $$$$$ J9307 Pralatrexate Injection $$$$$ J9310 Rituximab Injection $$$$$ J9315 Romidepsin Injection $$$$$ J9320 Streptozocin Injection 3 J9328 Temozolomide Injection 3 J9330 Temsirolimus Injection $$$ J9340 Thiotepa Injection $$$$$ J9351 Topotecan Injection $ J9354 Inj, Ado-Trastuzumab Emt 1Mg $$$$$ J9355 Trastuzumab Injection $$$$ J9357 Valrubicin Injection $$$$$ J9360 Vinblastine Sulfate Inj $ J9370 Vincristine Sulfate 1 Mg Inj $ J9371 Inj, Vincristine Sul Lip 1Mg 3 J9390 Vinorelbine Tartrate Inj $ J9395 Injection, Fulvestrant $$$ J9400 Inj, Ziv-Aflibercept, 1Mg $$$$ J9600 Porfimer Sodium Injection 3 Q2034 Agriflu Vaccine 0 Q2035 Afluria Vacc, 3 Yrs & Gt , Im 0 Q2036 Flulaval Vacc, 3 Yrs & Gt , Im 0 Q2037 Fluvirin Vacc, 3 Yrs & Gt , Im 0 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share Q2038 Fluzone Vacc, 3 Yrs & Gt , Im 0 Q2039 Influenza Virus Vaccine, Nos 0 90281 Immune Globulin (Ig), Human, For Intramuscular Use 1 90283 Immune Globulin (Igiv), Human, For Intravenous Use 1 90284 Immune Globulin (Scig), Human, For Use In Subcutaneous Infusions, 100 Mg, Each 3 90287 Botulinum Antitoxin, Equine, Any Route 1 90288 Botulism Immune Globulin, Human, For Intravenous Use 1 90291 Cytomegalovirus Immune Globulin (Cmv-Igiv), Human, For Intravenous Use 1 90296 Diphtheria Antitoxin, Equine, Any Route 1 90371 Hepatitis B Immune Globulin (Hbig), Human, For Intramuscular Use 1 90375 Rabies Immune Globulin (Rig), Human, For Intramuscular And/Or Subcutaneous Use $$ 90376 Rabies Immune Globulin, Heat-Treated (Rig-Ht), Human, For Intramuscular And/Or Subcutaneous Use 1 90378 Respiratory Syncytial Virus, Monoclonal Antibody, Recombinant, For Intramuscular Use, 50 Mg, Each $$ 90384 Rho(D) Immune Globulin (Rhig), Human, Full-Dose, For Intramuscular Use $ 90385 Rho(D) Immune Globulin (Rhig), Human, Mini-Dose, For Intramuscular Use $ 90386 Rho(D) Immune Globulin (Rhigiv), Human, For Intravenous Use 1 90389 Tetanus Immune Globulin (Tig), Human, For Intramuscular Use 1 90393 Vaccinia Immune Globulin, Human, For Intramuscular Use 1 90396 Varicella-Zoster Immune Globulin, Human, For Intramuscular Use 1 90476 Adenovirus Vaccine, Type 4, Live, For Oral Use 0 90477 Adenovirus Vaccine, Type 7, Live, For Oral Use 0 90581 Anthrax Vaccine, For Subcutaneous Or Intramuscular Use 0 90585 Bacillus Calmette-Guerin Vaccine (Bcg) For Tuberculosis, Live, For Percutaneous Use 0 90586 Bacillus Calmette-Guerin Vaccine (Bcg) For Bladder Cancer, Live, For Intravesical Use 0 90620 Meningococcal Recombinant Protein And Outer Membrane Vesicle Vaccine, Serogroup B (Menb), 2 Dose Schedule, For Intramuscular0 Use 90621 Meningococcal Recombinant Lipoprotein Vaccine, Serogroup B (Menb), 3 Dose Schedule, For Intramuscular Use 0 90630 Influenza Virus Vaccine, Quadrivalent (Iiv4), Split Virus, Preservative Free, For Intradermal Use 0 90632 Hepatitis A Vaccine (Hepa), Adult Dosage, For Intramuscular Use 0 90633 Hepatitis A Vaccine (Hepa), Pediatric/Adolescent Dosage-2 Dose Schedule, For Intramuscular Use 0 90634 Hepatitis A Vaccine (Hepa), Pediatric/Adolescent Dosage-3 Dose Schedule, For Intramuscular Use 0 90636 Hepatitis A And Hepatitis B Vaccine (Hepa-Hepb), Adult Dosage, For Intramuscular Use 0 90644 Meningococcal Conjugate Vaccine, Serogroups C & Y And Haemophilus Influenzae Type B Vaccine (Hib-Mency), 4 Dose Schedule,0 When Administered To Children 2-18 Months Of Age, For Intramuscular Use 90647 Haemophilus Influenzae Type B Vaccine (Hib), Prp-Omp Conjugate, 3 Dose Schedule, For Intramuscular Use 0 90648 Haemophilus Influenzae Type B Vaccine (Hib), Prp-T Conjugate, 4 Dose Schedule, For Intramuscular Use 0 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share 90649 Human Papillomavirus Vaccine, Types 6, 11, 16, 18, Quadrivalent (4Vhpv), 3 Dose Schedule, For Intramuscular Use 0 90650 Human Papillomavirus Vaccine, Types 16, 18, Bivalent (2Vhpv), 3 Dose Schedule, For Intramuscular Use 0 90651 Human Papillomavirus Vaccine Types 6, 11, 16, 18, 31, 33, 45, 52, 58, Nonavalent (9Vhpv), 3 Dose Schedule, For Intramuscular0 Use 90653 Influenza Vaccine, Inactivated (Iiv), Subunit, Adjuvanted, For Intramuscular Use 0 90654 Influenza Virus Vaccine, Trivalent (Iiv3), Split Virus, Preservative-Free, For Intradermal Use 0 90655 Influenza Virus Vaccine, Trivalent (Iiv3), Split Virus, Preservative Free, 0.25 Ml Dosage, For Intramuscular Use 0 90656 Influenza Virus Vaccine, Trivalent (Iiv3), Split Virus, Preservative Free, 0.5 Ml Dosage, For Intramuscular Use 0 90657 Influenza Virus Vaccine, Trivalent (Iiv3), Split Virus, 0.25 Ml Dosage, For Intramuscular Use 0 90658 Influenza Virus Vaccine, Trivalent (Iiv3), Split Virus, 0.5 Ml Dosage, For Intramuscular Use 0 90660 Influenza Virus Vaccine, Trivalent, Live (Laiv3), For Intranasal Use 0 90661 Influenza Virus Vaccine, Trivalent (Cciiv3), Derived From Cell Cultures, Subunit, Preservative And Antibiotic Free, 0.5 Ml Dosage,0 For Intramuscular Use 90662 Influenza Virus Vaccine (Iiv), Split Virus, Preservative Free, Enhanced Immunogenicity Via Increased Antigen Content, For Intramuscular0 Use 90670 Pneumococcal Conjugate Vaccine, 13 Valent (Pcv13), For Intramuscular Use 0 90672 Influenza Virus Vaccine, Quadrivalent, Live (Laiv4), For Intranasal Use 0 90673 Influenza Virus Vaccine, Trivalent (Riv3), Derived From Recombinant Dna, Hemagglutinin (Ha) Protein Only, Preservative And0 Antibiotic Free, For Intramuscular Use 90674 Influenza Virus Vaccine, Quadrivalent (Cciiv4), Derived From Cell Cultures, Subunit, Preservative And Antibiotic Free, 0.5 Ml 0Dosage, For Intramuscular Use 90675 Rabies Vaccine, For Intramuscular Use 0 90676 Rabies Vaccine, For Intradermal Use 0 90680 Rotavirus Vaccine, Pentavalent (Rv5), 3 Dose Schedule, Live, For Oral Use 0 90681 Rotavirus Vaccine, Human, Attenuated (Rv1), 2 Dose Schedule, Live, For Oral Use 0 90685 Influenza Virus Vaccine, Quadrivalent (Iiv4), Split Virus, Preservative Free, 0.25 Ml Dosage, For Intramuscular Use 0 90686 Influenza Virus Vaccine, Quadrivalent (Iiv4), Split Virus, Preservative Free, 0.5 Ml Dosage, For Intramuscular Use 0 90687 Influenza Virus Vaccine, Quadrivalent (Iiv4), Split Virus, 0.25 Ml Dosage, For Intramuscular Use 0 90688 Influenza Virus Vaccine, Quadrivalent (Iiv4), Split Virus, 0.5 Ml Dosage, For Intramuscular Use 0 90690 Typhoid Vaccine, Live, Oral 0 90691 Typhoid Vaccine, Vi Capsular Polysaccharide (Vicps), For Intramuscular Use 0 90696 Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine And Inactivated Poliovirus Vaccine (Dtap-Ipv), When Administered 0To Children 4 Through 6 Years Of Age, For Intramuscular Use 90698 Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Haemophilus Influenzae Type B, And Inactivated Poliovirus Vaccine,0 (Dtap-Ipv/Hib), For Intramuscular Use 90700 Diphtheria, Tetanus Toxoids, And Acellular Pertussis Vaccine (Dtap), When Administered To Individuals Younger Than 7 Years,0 For Intramuscular Use 90702 Diphtheria And Tetanus Toxoids Adsorbed (Dt) When Administered To Individuals Younger Than 7 Years, For Intramuscular 0Use 90707 Measles, Mumps And Rubella Virus Vaccine (Mmr), Live, For Subcutaneous Use 0 90710 Measles, Mumps, Rubella, And Varicella Vaccine (Mmrv), Live, For Subcutaneous Use 0 90713 Poliovirus Vaccine, Inactivated (Ipv), For Subcutaneous Or Intramuscular Use 0 90714 Tetanus And Diphtheria Toxoids Adsorbed (Td), Preservative Free, When Administered To Individuals 7 Years Or Older, For0 Intramuscular Use The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share 90715 Tetanus, Diphtheria Toxoids And Acellular Pertussis Vaccine (Tdap), When Administered To Individuals 7 Years Or Older, For0 Intramuscular Use 90716 Varicella Virus Vaccine (Var), Live, For Subcutaneous Use 0 90717 Yellow Fever Vaccine, Live, For Subcutaneous Use 0 90723 Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Hepatitis B, And Inactivated Poliovirus Vaccine (Dtap-Hepb-Ipv), For0 Intramuscular Use 90732 Pneumococcal Polysaccharide Vaccine, 23-Valent (Ppsv23), Adult Or Immunosuppressed Patient Dosage, When Administered0 To Individuals 2 Years Or Older, For Subcutaneous Or Intramuscular Use 90733 Meningococcal Polysaccharide Vaccine, Serogroups A, C, Y, W-135, Quadrivalent (Mpsv4), For Subcutaneous Use 0 90734 Meningococcal Conjugate Vaccine, Serogroups A, C, Y And W-135, Quadrivalent (Mcv4 Or Menacwy), For Intramuscular Use0 90736 Zoster (Shingles) Vaccine (Hzv), Live, For Subcutaneous Injection 0 90738 Japanese Encephalitis Virus Vaccine, Inactivated, For Intramuscular Use 0 90740 Hepatitis B Vaccine (Hepb), Dialysis Or Immunosuppressed Patient Dosage, 3 Dose Schedule, For Intramuscular Use 0 90743 Hepatitis B Vaccine (Hepb), Adolescent, 2 Dose Schedule, For Intramuscular Use 0 90744 Hepatitis B Vaccine (Hepb), Pediatric/Adolescent Dosage, 3 Dose Schedule, For Intramuscular Use 0 90746 Hepatitis B Vaccine (Hepb), Adult Dosage, 3 Dose Schedule, For Intramuscular Use 0 90747 Hepatitis B Vaccine (Hepb), Dialysis Or Immunosuppressed Patient Dosage, 4 Dose Schedule, For Intramuscular Use 0 90748 Hepatitis B And Haemophilus Influenzae Type B Vaccine (Hib-Hepb), For Intramuscular Use 0 94642 Aerosol Inhalation Of Pentamidine For Pneumocystis Carinii Pneumonia Treatment Or Prophylaxis 1 A4737 Injectable Anesthetic, For Dialysis, Per 10 Ml 3 J0120 Injection, Tetracycline, Up To 250 Mg $ J0190 Injection, Biperiden Lactate, Per 5 Mg 3 J0202 Injection, Alemtuzumab, 1 Mg 3 J0596 Injection, C1 Esterase Inhibitor (Recombinant), Ruconest, 10 Units 3 J0695 Injection, Ceftolozane 50 Mg And Tazobactam 25 Mg 3 J0714 Injection, Ceftazidime And Avibactam, 0.5 G/0.125 G 3 J0716 Injection, Centruroides Immune F(Ab)2, Up To 120 Milligrams 3 J0875 Injection, Dalbavancin, 5Mg $$$$ J1322 Injection, Elosulfase Alfa, 1 Mg 3 J1324 Injection, Enfuvirtide, 1 Mg 3 J1443 Injection, Ferric Pyrophosphate Citrate Solution, 0.1 Mg Of Iron 3 J1447 Injection, Tbo-Filgrastim, 1 Microgram $$ J1575 Injection, Immune Globulin/Hyaluronidase, (Hyqvia), 100 Mg Immuneglobulin 3 J1599 Injection, Immune Globulin, Intravenous, Non-Lyophilized (E.G., Liquid), Not Otherwise Specified, 500 Mg 3 J1675 Injection, Histrelin Acetate, 10 Micrograms $ J1741 Injection, Ibuprofen, 100 Mg 3 J1744 Injection, Icatibant, 1 Mg 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J1826 Injection, Interferon Beta-1A, 30 Mcg $$$$$ J1833 Injection, Isavuconazonium, 1 Mg 3 J2170 Injection, Mecasermin, 1 Mg 3 J2212 Injection, Methylnaltrexone, 0.1 Mg $ J2265 Injection, Minocycline Hydrochloride, 1 Mg 3 J2407 Injection, Oritavancin, 10 Mg $$$$ J2502 Injection, Pasireotide Long Acting, 1 Mg 3 J2547 Injection, Peramivir, 1 Mg 3 J2793 Injection, Rilonacept, 1 Mg 3 J2860 Injection, Siltuximab, 10 Mg 3 J3090 Injection, Tedizolid Phosphate, 1 Mg 3 J3145 Injection, Testosterone Undecanoate, 1 Mg $ J3380 Injection, Vedolizumab, 1 Mg $$$$$ J3530 Nasal Vaccine Inhalation 1 J7178 Injection, Human Fibrinogen Concentrate, 1 Mg $$$ J7180 Injection, Factor Xiii (Antihemophilic Factor, Human), 1 I.U. 3 J7181 Injection, Factor Xiii A-Subunit, (Recombinant), Per Iu 3 J7182 Injection, Factor Viii, (Antihemophilic Factor, Recombinant), (Novoeight), Per Iu 3 J7183 Injection, Von Willebrand Factor Complex (Human), Wilate, 1 I.U. Vwf:Rco 3 J7185 Injection, Factor Viii (Antihemophilic Factor, Recombinant) (Xyntha), Per I.U. 3 J7186 Injection, Antihemophilic Factor Viii/Von Willebrand Factor Complex (Human), Per Factor Viii I.U. $$$$$ J7187 Injection, Von Willebrand Factor Complex (Humate-P), Per Iu Vwf:Rco 3 J7188 Injection, Factor Viii (Antihemophilic Factor, Recombinant), (Obizur), Per I.U. 3 J7189 Factor Viia (Antihemophilic Factor, Recombinant), Per 1 Microgram $$$$ J7190 Factor Viii (Antihemophilic Factor, Human) Per I.U. $$$$$ J7191 Factor Viii (Antihemophilic Factor (Porcine)), Per I.U. 3 J7192 Factor Viii (Antihemophilic Factor, Recombinant) Per I.U., Not Otherwise Specified $$$$$ J7193 Factor Ix (Antihemophilic Factor, Purified, Non-Recombinant) Per I.U. $$$$$ J7194 Factor Ix, Complex, Per I.U. 3 J7195 Injection, Factor Ix (Antihemophilic Factor, Recombinant) Per Iu, Not Otherwise Specified $$$$$ J7196 Injection, Antithrombin Recombinant, 50 I.U. 3 J7197 Antithrombin Iii (Human), Per I.U. 3 J7198 Anti-Inhibitor, Per I.U. $$$ J7200 Injection, Factor Ix, (Antihemophilic Factor, Recombinant), Rixubis, Per Iu $$$$$ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J7201 Injection, Factor Ix, Fc Fusion Protein (Recombinant), Per Iu $$$$$ J7205 Injection, Factor Viii Fc Fusion Protein (Recombinant), Per Iu 3 J7297 Levonorgestrel-Releasing Intrauterine Contraceptive System, 52Mg, 3 Year Duration 0 J7298 Levonorgestrel-Releasing Intrauterine Contraceptive System, 52 Mg, 5 Year Duration 2 J7306 Levonorgestrel (Contraceptive) Implant System, Including Implants And Supplies 0 J7313 Injection, Fluocinolone Acetonide, Intravitreal Implant, 0.01 Mg $$$$$ J7328 Hyaluronan Or Derivative, Gel-Syn, For Intra-Articular Injection, 0.1 Mg 3 J7340 Carbidopa 5 Mg/Levodopa 20 Mg Enteral Suspension 3 J7604 Acetylcysteine, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per Gram 3 J7607 Levalbuterol, Inhalation Solution, Compounded Product, Administered Through Dme, Concentrated Form, 0.5 Mg 3 J7609 Albuterol, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose, 1 Mg $ J7610 Albuterol, Inhalation Solution, Compounded Product, Administered Through Dme, Concentrated Form, 1 Mg $ J7615 Levalbuterol, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose, 0.5 Mg $ J7627 Budesonide, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Up To 0.5 Mg 3 J7628 Bitolterol Mesylate, Inhalation Solution, Compounded Product, Administered Through Dme, Concentrated Form, Per Milligram3 J7629 Bitolterol Mesylate, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per Milligram 3 J7632 Cromolyn Sodium, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per 10 Milligrams3 J7634 Budesonide, Inhalation Solution, Compounded Product, Administered Through Dme, Concentrated Form, Per 0.25 Milligram3 J7640 Formoterol, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, 12 Micrograms 3 J7645 Ipratropium Bromide, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per Milligram $ J7647 Isoetharine Hcl, Inhalation Solution, Compounded Product, Administered Through Dme, Concentrated Form, Per Milligram 3 J7648 Isoetharine Hcl, Inhalation Solution, Fda-Approved Final Product, Non-Compounded, Administered Through Dme, Concentrated3 Form, Per Milligram J7650 Isoetharine Hcl, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per Milligram 3 J7657 Isoproterenol Hcl, Inhalation Solution, Compounded Product, Administered Through Dme, Concentrated Form, Per Milligram3 J7660 Isoproterenol Hcl, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per Milligram 3 J7667 Metaproterenol Sulfate, Inhalation Solution, Compounded Product, Concentrated Form, Per 10 Milligrams 3 J7670 Metaproterenol Sulfate, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per 10 Milligrams3 J7676 Pentamidine Isethionate, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per 300 Mg3 J7685 Tobramycin, Inhalation Solution, Compounded Product, Administered Through Dme, Unit Dose Form, Per 300 Milligrams 3 J8565 Gefitinib, Oral, 250 Mg 0 J8650 Nabilone, Oral, 1 Mg 0 J8655 Netupitant 300 Mg And Palonosetron 0.5 Mg 0 J9032 Injection, Belinostat, 10 Mg 3 J9039 Injection, Blinatumomab, 1 Microgram 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share J9262 Injection, Omacetaxine Mepesuccinate, 0.01 Mg 3 J9271 Injection, Pembrolizumab, 1 Mg 3 J9299 Injection, Nivolumab, 1 Mg $$$$$ J9308 Injection, Ramucirumab, 5 Mg $$$$$ Q0138 Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use) $ Q0139 Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (For Esrd On Dialysis) $ Q0161 Chlorpromazine Hydrochloride, 5 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute3 For An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0162 Ondansetron 1 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute For An Iv Anti-Emetic$ At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0163 Diphenhydramine Hydrochloride, 50 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute$ For An Iv Anti-Emetic At Time Of Chemotherapy Treatment Not To Exceed A 48 Hour Dosage Regimen Q0164 Prochlorperazine Maleate, 5 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute$ For An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0166 Granisetron Hydrochloride, 1 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute3 For An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 24 Hour Dosage Regimen Q0167 Dronabinol, 2.5 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute For An Iv Anti-Emetic3 At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0169 Promethazine Hydrochloride, 12.5 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute$ For An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0173 Trimethobenzamide Hydrochloride, 250 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic3 Substitute For An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0174 Thiethylperazine Maleate, 10 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute3 For An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0175 Perphenazine, 4 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute For An Iv 3Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0177 Hydroxyzine Pamoate, 25 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute For$ An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 48 Hour Dosage Regimen Q0180 Dolasetron Mesylate, 100 Mg, Oral, Fda Approved Prescription Anti-Emetic, For Use As A Complete Therapeutic Substitute For3 An Iv Anti-Emetic At The Time Of Chemotherapy Treatment, Not To Exceed A 24 Hour Dosage Regimen Q2009 Injection, Fosphenytoin, 50 Mg Phenytoin Equivalent 3 Q2017 Injection, Teniposide, 50 Mg 3 Q2043 Sipuleucel-T, Minimum Of 50 Million Autologous Cd54+ Cells Activated With Pap-Gm-Csf, Including Leukapheresis And All$$$$$ Other Preparatory Procedures, Per Infusion Q2049 Injection, Doxorubicin Hydrochloride, Liposomal, Imported Lipodox, 10 Mg 3 Q2050 Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, 10 Mg $$$ Q3027 Injection, Interferon Beta-1A, 1 Mcg For Intramuscular Use 3 Q3028 Injection, Interferon Beta-1A, 1 Mcg For Subcutaneous Use 3 Q4074 Iloprost, Inhalation Solution, Fda-Approved Final Product, Non-Compounded, Administered Through Dme, Unit Dose Form, Up3 To 20 Micrograms Q4081 Injection, Epoetin Alfa, 100 Units (For Esrd On Dialysis) $ Q5101 Injection, Filgrastim (G-Csf), Biosimilar, 1 Microgram $ Q5102 Injection, Infliximab, Biosimilar, 10 Mg 3 S0017 Injection, Aminocaproic Acid, 5 Grams 3 S0020 Injection, Bupivicaine Hydrochloride, 30 Ml $ S0021 Injection, Cefoperazone Sodium, 1 Gram 3 S0023 Injection, Cimetidine Hydrochloride, 300 Mg 3 S0028 Injection, Famotidine, 20 Mg $ The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672.

If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge.

CPT / HCPCS approximate Code Drug Description cost share S0030 Injection, Metronidazole, 500 Mg $ S0032 Injection, Nafcillin Sodium, 2 Grams $$$$ S0034 Injection, Ofloxacin, 400 Mg 3 S0039 Injection, Sulfamethoxazole And Trimethoprim, 10 Ml 3 S0040 Injection, Ticarcillin Disodium And Clavulanate Potassium, 3.1 Grams 3 S0073 Injection, Aztreonam, 500 Mg 3 S0074 Injection, Cefotetan Disodium, 500 Mg 3 S0077 Injection, Clindamycin Phosphate, 300 Mg $ S0078 Injection, Fosphenytoin Sodium, 750 Mg 3 S0080 Injection, Pentamidine Isethionate, 300 Mg 3 S0081 Injection, Piperacillin Sodium, 500 Mg 3 S0092 Injection, Hydromorphone Hydrochloride, 250 Mg (Loading Dose For Infusion Pump) 3 S0093 Injection, Morphine Sulfate, 500 Mg (Loading Dose For Infusion Pump) 3 S0119 Ondansetron, Oral, 4 Mg (For Circumstances Falling Under The Medicare Statute, Use Hcpcs Q Code) $ S0122 Injection, Menotropins, 75 Iu $$$ S0126 Injection, Follitropin Alfa, 75 Iu $$$$ S0128 Injection, Follitropin Beta, 75 Iu $$$ S0132 Injection, Ganirelix Acetate, 250 Mcg $$ S0145 Injection, Pegylated Interferon Alfa-2A, 180 Mcg Per Ml 3 S0148 Injection, Pegylated Interferon Alfa-2B, 10 Mcg 3 S0164 Injection, Pantoprazole Sodium, 40 Mg $ S0166 Injection, Olanzapine, 2.5 Mg 3 S0169 Calcitrol, 0.25 Microgram 3 S0171 Injection, Bumetanide, 0.5 Mg 3 S0172 Chlorambucil, Oral, 2 Mg 0 S0183 Prochlorperazine Maleate, Oral, 5 Mg (For Circumstances Falling Under The Medicare Statute, Use Q0164) 3 S0189 Testosterone Pellet, 75 Mg $$ S5550 Insulin, Rapid Onset, 5 Units 3 S5551 Insulin, Most Rapid Onset (Lispro Or Aspart); 5 Units 3 S5552 Insulin, Intermediate Acting (Nph Or Lente); 5 Units 3 S5553 Insulin, Long Acting; 5 Units 3