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CPT / HCPCS Code Drug Description Approximate Cost Share

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CPT / HCPCS Code Drug Description Approximate Cost Share 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. Legend $0 = no cost share $ = $100 and under $$ = over $100 to $250 $$$ = over $250 to $500 $$$$ = over $500 to $1000 $$$$$ = over $1000 1 = Please call HMSA Customer Service 1-800-776-4672 for cost share information. 2 = The cost share for this drug is dependent upon the diagnosis. Please call HMSA Customer Service at 1-800-772-4672 for more information. 3 = Cost share information for these drugs is dependent upon the dose prescribed. Please call HMSA Customer Service at 1- 800-772-4672 for more information. CPT / HCPCS approximate Code Drug Description cost share J0360 Hydralazine Hcl Injection $ J0364 Apomorphine Hydrochloride 3 J0365 Aprotonin, 10,000 Kiu 3 J0380 Inj Metaraminol Bitartrate 3 J0390 Chloroquine Injection 3 J0395 Arbutamine Hcl Injection 3 J0400 Aripiprazole Injection 3 J0401 Inj Aripiprazole Ext Rel 1Mg $$ 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 $$$ J0594 Busulfan Injection $$$$$ J0595 Butorphanol Tartrate 1 Mg 3 J0597 C-1 Esterase, Berinert 3 J0598 C-1 Esterase, Cinryze 3 J0600 Edetate Calcium Disodium Inj 3 J0610 Calcium Gluconate Injection $ J0620 Calcium Glycer & Lact/10 Ml 3 The information listed here is for our most prevalent plan. The amount you pay for a covered drug will depend on your plan’s coverage. Please refer to your Medical Plan GTB for more information. To find out the cost of your drugs, please contact HMSA Customer Service at 1-800-776-4672. If you receive services from a nonparticipating provider, you are responsible for a copayment plus any difference between the actual charge and the eligible charge. Legend $0 = no cost share $ = $100 and under $$ = over $100 to $250 $$$ = over $250 to $500 $$$$ = over $500 to $1000 $$$$$ = over $1000 1 = Please call HMSA Customer Service 1-800-776-4672 for cost share information. 2 = The cost share for this drug is dependent upon the diagnosis. Please call HMSA Customer Service at 1-800-772-4672 for more information. 3 = Cost share information for these drugs is dependent upon the dose prescribed. Please call HMSA Customer Service at 1- 800-772-4672 for more information. CPT / HCPCS approximate Code Drug Description cost share J0630 Calcitonin Salmon Injection 3 J0636 Inj Calcitriol Per 0.1 Mcg $ J0637 Caspofungin Acetate $ J0638 Canakinumab Injection 3 J0640 Leucovorin Calcium Injection $ J0641 Levoleucovorin Injection 3 J0670 Inj Mepivacaine Hcl/10 Ml $ J0690 Cefazolin Sodium Injection $ J0692 Cefepime Hcl For Injection $ J0694 Cefoxitin Sodium Injection 3 J0696 Ceftriaxone Sodium Injection $ J0697 Sterile Cefuroxime Injection $ J0698 Cefotaxime Sodium Injection $ J0702 Betamethasone Acet&Sod Phosp $ J0706 Caffeine Citrate Injection 3 J0710 Cephapirin Sodium Injection $ J0712 Ceftaroline Fosamil Inj $ J0713 Inj Ceftazidime Per 500 Mg $ J0715 Ceftizoxime Sodium / 500 Mg $ J0717 Certolizumab Pegol Inj 1Mg $$$$ J0720 Chloramphenicol Sodium Injec 3 J0725 Chorionic Gonadotropin/1000U $ J0735 Clonidine Hydrochloride 3 J0740 Cidofovir Injection $$ 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. Legend $0 = no cost share $ = $100 and under $$ = over $100 to $250 $$$ = over $250 to $500 $$$$ = over $500 to $1000 $$$$$ = over $1000 1 = Please call HMSA Customer Service 1-800-776-4672 for cost share information. 2 = The cost share for this drug is dependent upon the diagnosis. Please call HMSA Customer Service at 1-800-772-4672 for more information. 3 = Cost share information for these drugs is dependent upon the dose prescribed. Please call HMSA Customer Service at 1- 800-772-4672 for more information. CPT / HCPCS approximate Code Drug Description cost share J0834 Cosyntropin Cortrosyn Inj $ J0840 Crotalidae Poly Immune Fab 3 J0850 Cytomegalovirus Imm Iv /Vial $$$ 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. 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
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