Codes Drug Name J3262 Actemra (Tocilizumab) IV Only C9399, A4641

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Codes Drug Name J3262 Actemra (tocilizumab) IV only C9399, A4641 Azedra (iobenguane I 131) C9491, J9023 Bavencio (avelumab) J9032 Beleodaq (belinostat) J9034 Bendeka (bendamustine) C9028 Besponsa (inotuzumab ozogamicin) J9039 Blincyto (bliantumab) J0585 Botox (onabotulinumtoxin A) C9014 Brineura (cerliponase alfa) J1566 Carimune NF(immune globulin) IV only J0717 Cimzia (certolizumab) IV only C9481, J2786 Cinqair (reslizumab) J9308 Cyramza (ramucirumab) C9476, J9145 Darzalex (daratumumab) J0586 Dysport (abobotulinimumtoxin A) C9477, J9176 Empliciti (elotuzumab) J3380 Entyvio (vedolizumab) J9019 Erwinaze (asparaginase Erwinia chrysanthemi) C9484, J1428 Exondys 51 (eteplirsen) C9466 Fasenra (benralizumab) J1572 Flebogamma (immune globulin) IV only J1460, J1560 GamaSTAN S/D (gamma globulin) IV only J1569 Gammagard (immune globulin) IV only J1557 Gammaplex (immune globulin) IV only J1561 Gamunex/Gamunex-C (immune globulin) IV only J9301 Gazyva (obinutuzumab) J1670 HyperTET S/D (tetanus immune globulin) (Medicare members only) C9492, J9173 Imfinzi (durvalumab) J9325 Imlygic (talimogene laherparepvec) C9478, J2840 Kanuma (sebelipase alfa) J9271 Keytruda (pembrolizumab) J2507 Krystexxa (pegloticase) Q2040 Kymirah (tisagenlecleucel) C9485, J9285 Lartruvo (olaratumab) J0202 Lemtrada (alemtuzumab) C9031 Lutathera (lutetium Lu 177 dotatate) C9032 Luxturna (voretigene neparvovec-rzyl) J9203 Mylotarg (gemtuzumab ozogamicin) J0587 Myobloc (rimabotulinumtoxin B) J2182 Nucala (mepolizumab) C9494, J2350 Ocrevus (ocrelizumab) J1568 Octagam (immune globulin) IV only J9205 Onivyde (irinotecan lisosome inj) J9299 Opdivo (nivolumab) J0129 Orencia (abatacept) IV only J9295 Portrazza (necitumumab) J1459 Privigen (immune globulin) IV only J0570 Probuphine (buprenorphine subdermal implant) Q2043 Provenge (sipuleucel-T) C9493 Radicava (edaravone) J0596 Ruconest (C1 estrease inhibitor) J1602 Simponi Aria (golimumab) IV only J1300 Soliris (eculizumab) C9489, J2326 Spinraza (nusinersen) Capital Health Plan MMS Dept. Updated 01/25/18, 03/23/18, 04/17/18, 08/21/18, 12/18/18 Q9989, J3358 Stelara (ustekinumab) IV only CPT 90378 Synagis (palivizumab) C9483, J9022 Tecentriq (atezolizumab) J9033 Treanda (bendamustine) J2323 Tysabri (natalizaumab) J1325 Veletri (epoprostenol) C9024 Vyxeos (daunorubicin; cytarabine) J0588 Xeomin (incobotulinim toxin a) A9606 Xofigo (radium Ra 223 dichloride injection) J2357 Xolair (omalizumab) J9228 Yervoy (ipilimumab) Q2041 Yescarta (axicabtagene ciloleucel) C9480 Yondelis (trabectedin) J9999 Unclassified Antineoplastic drugs J3590, C9399 Unclassified biologics J7999 Unclassified compounded drug J3490 Unclassified drugs J1599 Unclassified Immune globulin IV only Capital Health Plan MMS Dept. Updated 01/25/18, 03/23/18, 04/17/18, 08/21/18, 12/18/18.

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