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CPT/HCPCS Medication Code Reference List

Prior Authorization Code Description Required Immune Globulin (Ig), human, for intramuscular use (Code price is 90281 per 2 mL) Immune Globulin (IgIV), human, for intravenous use (Further 90283 Documentation Requested) Yes Immune Globulin (SCIg), human, for use in subcutaneous infusions, 90284 100 mg, each 90287 Botulinum antitoxin, equine, any route 90288 Botulism immune globulin, human, for intravenous use Cytomegalovirus immune globulin (CMV‐IgIV), human, for 90291 intravenous use 90296 Diphtheria antitoxin, equine, any route Hepatitis B Immune Globulin (HBIg), human, for intramuscular use 90371 (Code Price is per 1 mL) Rabies Immune Globulin (RIg), human, for intramuscular and/or 90375 subcutaneous use Rabies Immune Globulin, heat‐treated (RIg‐HT), human, for 90376 intramuscular and/or subcutaneous use (Code Price is per 150 IU) Respiratory syncytial virus, monoclonal antibody, recombinant, for 90378 intramuscular use, 50 mg, each Rho(D) Immune Globulin (RhIg), human, full dose, for intramuscular 90384 use. Rho(D) Immune Globulin (RhIg), human, mini dose, for 90385 intramuscular use. (Code Price is per 50 mcg) Rho(D) Immune Globulin (RhIgIV), human, for intravenous use (Code 90386 Price is per 1500 IU)

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 1 of 35 Prior Authorization Code Description Required 90389 Tetanus Immune Globulin (TIg), human, for intramuscular use 90393 Vaccinia immune globulin, human, for intramuscular use Varicella‐zoster Immune Globulin, human, for intramuscular use. 90396 (Code Price is per 125 units) 90476 Adenovirus vaccine, type 4, live, for oral use 90477 Adenovirus vaccine, type 7, live, for oral use 90581 Anthrax vaccine, for subcutaneous use (Code price is per 0.5 mL) Bacillus Calmette‐Guerin vaccine (BCG) for tuberculosis, live, for 90585 percutaneous use (Code Price is per 50 mg) Bacillus Calmette‐Guerin vaccine (BCG) for bladder cancer, live, for 90586 intravesical use. Hepatitis A vaccine, adult dosage, for intramuscular use (Code Price 90632 is per 1 mL) Hepatitis A vaccine, pediatric/adolescent dosage (2‐dose schedule), 90633 for intramuscular use (Code Price is per 0.5 mL) Hepatitis A vaccine, pediatric/adolescent dosage‐3 dose schedule, 90634 for intramuscular use Hepatitis A & Hepatitis B vaccine (HepA‐HepB) adult dosage, for 90636 intramuscular use. (Code Price is per 1 mL) Hemophilus influenza b vaccine (Hib), HbOC conjugate (4‐dose 90645 schedule), for intramuscular use. Hemophilus influenza b vaccine (Hib), PRP‐OMP conjugate (3‐dose 90647 schedule), for intramuscular use. (Code price is per dose = 0.5 mL) Hemophilus influenza b vaccine (Hib), PRP‐T conjugate (4‐dose 90648 schedule), for intramuscular use. (Code price is per 0.5mL dose) Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 90649 (quadrivalent), 3 dose schedule, for intramuscular use Yes for females less than 10 or greater than 26 Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose years old and all 90650 schedule, for intramuscular use males

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 2 of 35 Prior Authorization Code Description Required Influenza virus vaccine, split virus, preservative free, for children 6‐ 90655 35 months of age, for intramuscular use (Code price is per 0.25 mL) Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years of age and above, for intramuscular use (Code price is per 0.5 mL) (Note: Fluvirin is indicated for use in those 4 90656 years of age and older) Influenza virus vaccine, split virus, for children 6‐35 months of age, 90657 for intramuscular use (Code Price is per 0.25 mL dose) Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use (Code price is per 0.5 mL)(Note: Fluvirin is indicated for use in those 4 years of age and 90658 older) Influenza virus vaccine, live, for intranasal use (Code price is per 0.5 90660 mL) Non‐covered; Influenza virus vaccine, derived from cell cultures, subunit, No FDA 90661 preservative and antibiotic free, for intramuscular use approval Influenza virus vaccine, split virus, preservative free, enhanced Non‐covered; immunogenicity via increased antigen content, for intramuscular No FDA 90662 use approval 90663 Influenza virus vaccine, pandemic formulation Influenza virus vaccine, pandemic formulation, live, for intranasal 90664 use Lyme disease vaccine, adult dosage, for intramuscular use. 90665 (30mcg/0.5ml) (All NDC's are inactive) Influenza virus vaccine, pandemic formulation, preservative free, for 90666 intramuscular use Influenza virus vaccine, pandemic formulation, split virus, 90667 adjuvanted, for intramuscular use Influenza virus vaccine, pandemic formulation, split virus, for 90668 intramuscular use

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 3 of 35 Prior Authorization Code Description Required Pneumococcal conjugate vaccine, 7 valent, for intramuscular use 90669 (Code Price is per 0.5 mL dose) 90675 Rabies vaccine, for intramuscular use.(Code price is per 1 mL) Rabies vaccine, for intradermal use (Code Price is per 0.1 90676 mL)(Product not available) 90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral 90681 use Typhoid vaccine, live, oral (Code Price is based one course of 90690 therapy = 4 capsules) Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for 90691 intramuscular use. (Code price is per 0.5 mL) Typhoid vaccine, heat‐ and phenol‐inactivated (HP), for subcutaneous or intradermal use. (Code Price is per 0.5 mL)(Product 90692 not available) Typhoid vaccine, acetone‐killed, dried (AKD), for subcutaneous use 90693 (U.S. military) Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP‐IPV), when administered to 90696 children 4 through 6 years of age, for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP‐Hib‐ 90698 IPV), for intramuscular use Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals younger than seven years, for intramuscular 90700 use (Code price is per 0.5 mL dose) Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), 90701 for intramuscular use Diphtheria and tetanus toxoids (DT) adsorbed, for use in individuals younger than 7 years, for intramuscular use.(Code price is per 0.5 90702 mL) Tetanus toxoid adsorbed, for intramuscular use (Code Price is per 90703 0.5 mL)

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 4 of 35 Prior Authorization Code Description Required Mumps virus vaccine, live, for subcutaneous use (Code Price is per 90704 0.5 mL dose) Measles virus vaccine, live, for subcutaneous use (Code Price is per 90705 0.5 mL) Rubella virus vaccine, live, for subcutaneous use (Code Price is per 90706 0.5 mL) Measles, mumps and rubella virus vaccine (MMR), live, for 90707 subcutaneous use (Code Price is per 0.5 mL) Measles and rubella virus vaccine, live, for subcutaneous use (Code 90708 Price is per 0.5 mL) Measles, mumps, rubella, and varicella vaccine (MMR), live, for 90710 subcutaneous use Poliovirus vaccine (any type[s]) (OPV), live, for oral use. (All NDC's 90712 are inactive) Poliovirus vaccine, inactivated, (IPV), for subcutaneous or 90713 intramuscular use (Code Price is per 0.5 mL dose) Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals seven years or older, for intramuscular use (Code Price is per 0.5 mL)(Note: Code is not effective for billing Medicare 90714 until 7/1/05) Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular 90715 use Varicella virus vaccine, live, for subcutaneous use (Code Price is per 90716 0.5 mL) Yellow fever vaccine, live, for subcutaneous use (Code Price is per 90717 0.5 mL) Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular use (Code Price is per 0.5 90718 mL) 90719 Diphtheria toxoid, for intramuscular use

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 5 of 35 Prior Authorization Code Description Required Diphtheria, tetanus toxoids, and whole cell pertussis and Hemophilus influenza B vaccine (DTP‐Hib), for intramuscular use. 90720 (Code price is per 0.5 mL dose) (All NDC's inactive since 3/03) Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DTP‐Hib), for intramuscular use 90721 (Code Price is per dose) Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B and poliovirus vaccine, inactivated (DtaP‐HepB‐IPV), for 90723 intramuscular use. (Code price is per 0.5 mL) 90725 Cholera vaccine, for injectable use. (All NDC's are inactive) 90727 Plague vaccine, for intramuscular use Pneumococcal polysaccharide vaccine, 23‐valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use. (Code price is per 0.5 90732 mL dose) Meningococcal polysaccharide vaccine (any group(s)), for 90733 subcutaneous use (Code Price is per 0.5 mL) Meningococcal conjugate vaccine, serogroups A, C, Y and W‐135 90734 (tetravalent), for intramuscular use Japanese encephalitis virus vaccine, for subcutaneous use. (Code 90735 Price is per 1 mL) 90736 Zoster (shingles) vaccine, live, for subcutaneous injection Japanese encephalitis virus vaccine, inactivated, for intramuscular 90738 use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3‐dose schedule), for intramuscular use. (Code price is per 40mcg = 90740 1 dose) Hepatitis B vaccine, adolescent dosage (2‐dose schedule), for intramuscular use. (Code price is per dose) (Recombivax HB 10mcg = 90743 one dose) Hepatitis B vaccine, pediatric/adolescent dosage (3‐dose schedule), 90744 for intramuscular use (Code price is per dose) 90746 Hepatitis B vaccine, adult dosage, for intramuscular use.

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 6 of 35 Prior Authorization Code Description Required Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4‐dose schedule), for intramuscular use. (Code price is per 40mcg = 90747 1 dose) Hepatitis B and Hemophilus influenza b vaccine (HepB‐Hib), for 90748 intramuscular use. (Code price is per 0.5 mL dose) A4231 Infusion set for external insulin pump, needle type A4250 Urine test or reagent strips or tablets (100 tablets or strips) Pediculosis (lice infestation) treatment, topical for administration by A9180 patient/caretaker (Code Price is per 30 mL) Technetium Tc‐99m depreotide, diagnostic, per study dose, up to 35 A9536 millicuries Technetium Tc‐99m mebrofenin, diagnostic, per study dose, up to A9537 15 millicuries A9556 Gallium Ga‐67 citrate, diagnostic, per millicurie A9558 Xenon Xe‐133 gas, diagnostic, per 10 millicuries Technetium Tc‐99m oxidronate, diagnostic, per study dose, up to 30 A9561 millicuries Technetium Tc‐99m mertiatide, diagnostic, per study dose, up to 15 A9562 millicuries A9563 Sodium phosphate P‐32, therapeutic, per millicurie A9564 Chromic phosphate P‐32 suspension, therapeutic, per millicurie J0120 Injection, tetracycline, up to 250 mg J0128 Injection, abarelix, 10 mg Yes ‐ Available only through specialty pharmacy J0129 Injection, abatecept, 10 mg vendor J0130 Injection abciximab, 10 mg J0132 Injection, acetylcysteine, 100 mg J0133 Injection, acyclovir, 5 mg J0135 Injection, adalimumab, 20 mg Yes

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 7 of 35 Prior Authorization Code Description Required Injection, adenosine for therapeutic or diagnostic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead J0150 use A9270) Injection, adenosine for diagnostic use, 30 mg (not to be used to J0152 report any adenosine phosphate compounds; instead use A9270) Injection, adrenalin, epinephrine, up to 1ml ampule (Code Price is J0170 based on 1 mg/mL product) J0180 Injection, agalsidase beta, 1 mg J0190 Injection, biperiden lactate, per 5 mg J0200 Injection, alatrofloxacin mesylate, 100 mg J0205 Injection, alglucerase, per 10 units J0207 Injection, amifostine, 500mg J0210 Injection, methyldopate HCl, up to 250mg Injection, alefacept, 0.5mg (Note: Code Price is based on IM product J0215 ‐ IV product is no longer manufactured) Yes J0220 Injection, alglucosidase alfa, 10 mg J0256 Injection, alpha 1‐proteinase inhibitor, human, 10mg Injection, alprostadil, 1.25mcg, administered under direct physician J0270 supervision, excludes self administration Not a Covered J0275 Alprostadil urethral suppository Benefit J0278 Injection, amikacin sulfate, 100 mg J0280 Injection, aminophyllin, up to 250mg J0282 Injection, amiodarone hydrochloride, 30mg J0285 Injection, amphotericin B, 50mg J0287 Injection, amphotericin B lipid complex, 10 mg J0288 Injection, amphotericin B cholesteryl sulfate complex, 10 mg J0289 Injection, amphotericin B liposome, 10 mg J0290 Injection, ampicillin sodium, 500mg J0295 Injection, ampicillin sodium/sulbactam sodium, per 1.5g J0300 Injection, amobarbital, up to 125mg J0330 Injection, succinylcholine chloride, up to 20mg J0348 Injection, anidulafungin, 1 mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 8 of 35 Prior Authorization Code Description Required J0350 Injection, anistreplase, per 30 units J0360 Injection, hydralazine HCl, up to 20mg J0364 Injection, apomorphine HCI, 1 mg J0365 Injection, aprotinin, 10,000 kiu J0380 Injection, metaraminol bitartrate, per 10mg J0390 Injection, chloroquine hydrochloride, up to 250mg J0395 Injection, arbutamine HCl, 1mg (All NDC's inactive since 1/02) J0400 Injection, aripirazole, intramuscular, 0.25 mg J0456 Injection, azithromycin, 500mg J0461 Injection, atropine sulfate, 0.01 MG J0470 Injection, dimercaprol, per 100mg J0475 Injection, baclofen 10mg J0476 Injection, baclofen, 50mcg, for intrathecal trial J0480 Injection, basiliximab, 20 mg J0500 Injection, dicyclomine HCl, up to 20mg J0515 Injection, benztropine mesylate, per 1mg Injection, bethanechol chloride, Myotonachol or Urecholine, up to J0520 5mg (All NDC's inactive since 6/03) Injection, Penicillin G Benzathine and Penicillin G Procaine, 2500 J0559 units J0560 Injection, penicillin G benzathine, up to 600,000 units J0570 Injection, penicillin G benzathine, up to 1,200,000 units J0580 Injection, penicillin G benzathine, up to 2,400,000 units J0583 Injection, bivalirudin, 1mg J0585 Botulinum toxin type A, per unit Yes J0586 Injection, Abobotulinumtoxina, 5 units Yes J0587 Injection, rimabotulinumtoxinB, 100 units Yes J0592 Injection, buprenorphine hydrochloride, 0.1 mg J0594 Injection, busulfan, 1 mg J0595 Injection, butorphanol tartrate, 1mg J0598 Injection, C1 Esterase Inhibitor (human), 10 units Yes J0600 Injection, edetate calcium disodium, up to 1000 mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 9 of 35 Prior Authorization Code Description Required J0610 Injection, calcium gluconate, per 10ml J0620 Injection, calcium glycerophosphate and calcium lactate, per 10mL. J0630 Injection, calcitonin salmon, up to 400 units J0636 Injection, calcitriol, 0.1 mcg J0637 Injection, caspofungin acetate, 5 mg J0640 Injection, leucovorin calcium, per 50mg J0641 Injection, levoleucovorin calcium, 0.5 mg Injection, mepivacaine hydrochloride, per 10ml (Further J0670 Documentation Requested) J0690 Injection, cefazolin sodium, 500mg J0692 Injection, cefepime HCl, 500 mg J0694 Injection, cefoxitin sodium, 1g J0696 Injection, ceftriaxone sodium, per 250mg J0697 Injection, sterile cefuroxime sodium, per 750mg J0698 Cefotaxime sodium, per g Injection, betamethasone acetate and betamethasone sodium J0702 phosphate, per 3mg Injection, betamethasone sodium phosphate, per 4mg (All NDC's J0704 inactive since 12/02) J0706 Injection, caffeine citrate, 5 mg Injection, cephapirin sodium, up to 1g (All NDC's inactive since J0710 12/04) J0713 Injection, ceftazidime, per 500mg J0715 Injection, ceftizoxime sodium, per 500mg J0718 Injection, Certolizumab Pegol, 1 MG Yes J0720 Injection, chloramphenicol sodium succinate, up to 1g J0725 Injection, chorionic gonadotropin, per 1,000 USP units Yes J0735 Injection, clonidine hydrochloride, 1mg J0740 Injection, cidofovir, 375mg J0743 Injection, cilastatin sodium; imipenem, per 250mg J0744 Injection, ciprofloxacin for intravenous infusion, 200 mg J0745 Injection, codeine phosphate, per 30mg J0760 Injection, colchicine, per 1mg J0770 Injection, colistimethate sodium, up to 150mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 10 of 35 Prior Authorization Code Description Required J0780 Injection, prochlorperazine, up to 10mg J0795 Injection, corticorelin ovine triflutate, 1 microgram J0800 Injection, corticotropin, up to 40 units Yes J0833 Injection, Cosyntropin, Not Otherwise Specified, 0.25 MG J0834 Injection, Cosyntropin (Cortrosyn), 0.25 MG Injection, cytomegalovirus, immune globulin intravenous (human), J0850 per vial (Code Price is per 50 mL) J0878 Injection, daptomycin, 1 mg J0881 Injection, darbepoetin alfa, 1 microgram (non‐ESRD use) Yes J0882 Injection, darbepoetin alfa, 1 microgram (for ESRD on dialysis) J0885 Injection, epoetin alfa, (for non‐ESRD use), 1000 units Yes J0886 Injection, epoetin alfa, 1000 units (for ESRD on dialysis) J0894 Injection, decitabine, 1 mg J0895 Injection, deferoxamine mesylate, 500mg J0900 Injection, testosterone enanthate and estradiol valerate, up to 1cc J0945 Injection, brompheniramine maleate, per 10mg J0970 Injection, estradiol valerate, up to 40mg J1000 Injection, depo‐estradiol cypionate, up to 5mg J1020 Injection, methylprednisolone acetate, 20mg J1030 Injection, methylprednisolone acetate, 40mg J1040 Injection, methylprednisolone acetate, 80mg J1051 Injection, medroxyprogesterone acetate, 50 mg Injection, medroxyprogesterone acetate for contraceptive use, J1055 150mg Injection, medroxyprogesterone acetate/estradiol cypionate, 5 J1056 mg/25 mg (All NDC's inactive since 1/05) Injection, testosterone cypionate and estradiol cypionate, up to 1mL J1060 (All NDC's inactive since 3/03) J1070 Injection, testosterone cypionate, up to 100mg J1080 Injection, testosterone cypionate, 1cc, 200mg J1094 Injection, dexamethasone acetate, 1 mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 11 of 35 Prior Authorization Code Description Required J1100 Injection, dexamethasone sodium phosphate, 1mg J1110 Injection, dihydroergotamine mesylate, per 1mg J1120 Injection, acetazolamide sodium, up to 500mg J1160 Injection, digoxin, up to 0.5mg J1162 Injection, digoxin immune fab (ovine), per vial J1165 Injection, phenytoin sodium, per 50mg J1170 Injection, hydromorphone, up to 4mg J1180 Injection, dyphylline, up to 500mg J1190 Injection, dexrazoxane hydrochloride, per 250mg J1200 Injection, diphenhydramine HCl, up to 50mg J1205 Injection, chlorothiazide sodium, per 500mg J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50mL J1230 Injection, methadone HCl, up to 10mg J1240 Injection, dimenhydrinate, up to 50mg J1245 Injection, dipyridamole, per 10mg J1250 Injection, dobutamine hydrochloride, per 250mg J1260 Injection, dolasetron mesylate, 10 mg J1265 Injection, dopamine HCl, 40 mg J1270 Injection, doxercalciferol, 1 mcg J1300 Injection, eculizumab, 10 mg Injection, amitriptyline HCl, up to 20mg (All NDC's inactive since J1320 7/99) J1324 Injection, enfuvirtide, 1 mg J1325 Injection, epoprostenol, 0.5mg Yes J1327 Injection, eptifbatide, 5mg J1330 Injection, ergonovine maleate, up to 0.2mg J1335 Injection, ertapenem sodium, 500mg J1364 Injection, erythromycin lactobionate, per 500mg J1380 Injection, estradiol valerate, up to 10mg J1390 Injection, estradiol valerate, up to 20mg J1410 Injection, estrogens, conjugated, per 25mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 12 of 35 Prior Authorization Code Description Required J1430 Injection, ethanolamine oleate, 100 mg J1435 Injection, estrone, per 1mg J1436 Injection, etidronate disodium, per 300mg Injection, etanercept, 25mg (code may be used for Medicare when drug administered under the direct supervision of a physician; not J1438 for use when drug is self‐administered) Yes J1440 Injection, filgrastim (G‐CSF), 300mcg J1441 Injection, filgrastim (G‐CSF), 480mcg J1450 Injection, fluconazole, 200mg J1451 Injection, fomepizole, 15 mg Injection, fomivirsen sodium, intraocular, 1.65mg (All NDC's inactive J1452 since 9/05) J1453 Injection, fosaprepitant, 1 mg J1455 Injection, foscarnet sodium, per 1,000mg J1457 Injection, gallium nitrate, 1 mg J1458 Injection, galsulfase, 1 mg Injection, immune globulin (Privigen), intravenous, nonlyophilized J1459 (e.g., liquid), 500 mg YES J1460 Injection, gamma globulin, intramuscular, 1cc J1470 Injection, gamma globulin, intramuscular, 2cc J1480 Injection, gamma globulin, intramuscular, 3cc J1490 Injection, gamma globulin, intramuscular, 4cc J1500 Injection, gamma globulin, intramuscular, 5cc J1510 Injection, gamma globulin, intramuscular, 6cc J1520 Injection, gamma globulin, intramuscular, 7cc J1530 Injection, gamma globulin, intramuscular, 8cc J1540 Injection, gamma globulin, intramuscular, 9cc J1550 Injection, gamma globulin, intramuscular, 10cc J1560 Injection, gamma globulin, intramuscular, over 10 cc Injection, immune globulin, (Gamunex), intravenous, nonlyophilized J1561 (e.g. Liquid), 500 mg Yes

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 13 of 35 Prior Authorization Code Description Required

Yes ‐ Available only through specialty pharmacy J1562 Injection, immune globulin, (Vivaglobin), 100 mg vendor Injection, immune globulin, intravenous, lyophilized (e.g powder), J1566 500 mg Yes Injection, immune globulin, (Octagam), intravenous, nonlyophilized J1568 (e.g., liquid), 500 mg Yes Injection, immune globulin, (Gammagard liquid), intravenous, J1569 nonlyophilized, (e.g., liquid), 500 mg Yes J1570 Injection, ganciclovir sodium, 500mg Injection, hepatitis B immune globulin (Hepagam B), intramuscular, J1571 0.5 ml Injection, immune globulin, (Flebogamma/Flebogamma Dif), J1572 intravenous, nonlyophilized (e.g., liquid), 500 mg Yes Injection, hepatitis B immune globulin (Hepagam B), intravenous, J1573 0.5 ml J1580 Injection, garamycin, gentamicin, up to 80mg J1590 Injection, gatifloxacin, 10 mg J1595 Injection, glatiramer acetate, 20mg J1600 Injection, gold sodium thiomalate, up to 50mg J1610 Injection, glucagon hydrochloride, per 1mg J1620 Injection, gonadorelin hydrochloride, per 100mcg Yes J1626 Injection, granisetron hydrochloride, 100mcg J1630 Injection, haloperidol, up to 5mg J1631 Injection, haloperidol decanoate, per 50mg J1640 Injection, hemin, 1 mg J1642 Injection, heparin sodium (heparin lock flush), per 10 units J1644 Injection, heparin sodium, per 1,000 units J1645 Injection, dalteparin sodium, per 2,500 IU

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 14 of 35 Prior Authorization Code Description Required J1650 Injection, enoxaparin sodium, 10 mg J1652 Injection, fondaparinux sodium, 0.5 mg J1655 Injection, tinzaparin sodium, 1000 IU J1670 Injection, tetanus immune globulin, human, up to 250 units J1675 Injection, histrelin acetate, 10 mcg J1680 Injection, human fibrinogen concentrate, 100 mg J1700 Injection, hydrocortisone acetate, up to 25 mg Injection, hydrocortisone sodium phosphate, up to 50mg (All NDC's J1710 inactive since 9/02) J1720 Injection, hydrocortisone sodium succinate, up to 100mg J1730 Injection, diazoxide, up to 300mg J1740 Injection, ibandronate sodium, 1 mg Yes J1742 Injection, ibutilide fumarate, 1mg J1743 Injection, idursulfase, 1 mg J1745 Injection, infliximab, 10mg Yes Injection, iron dextran, 50mg (Code deleted effective 1/1/06 refer J1750 to J1751 and J1752) J1756 Injection, iron sucrose, 1 mg J1785 Injection, imiglucerase, per unit J1790 Injection, droperidol, up to 5mg J1800 Injection, propranolol HCl, up to 1mg J1810 Injection, droperidol and fentanyl citrate, up to 2mL ampule J1815 Injection, insulin, per 5 units Insulin for administration through DME (i.e., insulin pump) per 50 J1817 units J1825 Injection, interferon beta‐1a, 33 mcg (See also Q3025) Yes Injection, interferon beta‐1B, 0.25mg (code may be used for Medicare when drug administered under direct supervision of a J1830 physician; not for use if self‐administered.) Yes J1835 Injection, intraconazole, 50 mg J1840 Injection, kanamycin sulfate, up to 500mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 15 of 35 Prior Authorization Code Description Required Injection, kanamycin sulfate, up to 75mg (All NDC's inactive since J1850 6/01) J1885 Injection, ketorolac tromethamine, per 15mg Injection, cephalothin sodium, up to 1g (All NDC's inactive since J1890 5/01) J1930 Injection, Ianreotide, 1 mg J1931 Injection, laronidase, 0.1 mg J1940 Injection, furosemide, up to 20mg J1945 Injection, lepirudin, 50 mg Yes ‐ For Female J1950 Injection, leuprolide acetate (for depot suspension), per 3.75mg Patients Only J1953 Injection, Levetiracetam, 10 mg J1955 Injection, levocarnitine, per 1g J1956 Injection, levofloxacin, 250mg J1960 Injection, levorphanol tartrate, up to 2mg J1980 Injection, hyoscyamine sulfate, up to 0.25mg J1990 Injection, chlordiazepoxide HCl, up to 100mg J2001 Injection, lidocaine HCL for intravenous infusion, 10mg J2010 Injection, lincomycin HCl, up to 300mg J2020 Injection, linezolid, 200 mg Yes J2060 Injection, lorazepam, 2mg J2150 Injection, mannitol, 25% in 50mL J2170 Injection, mecasermin, 1 mg Yes J2175 Injection, meperidine hydrochloride, per 100mg Injection, meperidine and promethazine HCl, up to 50mg (All NDC's J2180 inactive since 10/01) J2185 Injection, meropenem, 100mg J2210 Injection, methylergonovine maleate, up to 0.2mg J2248 Injection, micafungin sodium, 1 mg J2250 Injection, midazolam hydrochloride, per 1mg J2260 Injection, milrinone lactate, per 5 mg J2270 Injection, morphine sulfate, up to 10mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 16 of 35 Prior Authorization Code Description Required J2271 Injection, morphine sulfate, 100mg Injection, morphine sulfate (preservative‐free sterile solution), per J2275 10mg J2278 Injection, ziconotide, 1 microgram J2280 Injection, moxifloxacin, 100mg J2300 Injection, nalbuphine hydrochloride, per 10mg J2310 Injection, naloxone hydrochloride, per 1mg J2315 Injection, naltrexone, depot form, 1 mg Yes J2320 Injection, nandrolone decanoate, up to 50mg Yes J2321 Injection, nandrolone decanoate, up to 100mg Yes J2322 Injection, nandrolone decanoate, up to 200mg Yes J2323 Injection, natalizumab, 1 mg J2325 Injection, nesiritide, 0.1 mg J2353 Injection, octreotide, depot form for intramuscular injection, 1mg Injection, octreotide, nondepot form for subcutaneous or J2354 intravenous injection, 25 mcg J2355 Injection, oprelvekin, 5mg J2357 Injection, omalizumab, 5 mg Yes J2360 Injection, orphenadrine citrate, up to 60mg J2370 Injection, phenylephrine HCl, up to 1ml J2400 Injection, chloroprocaine hydrochloride, per 30ml J2405 Injection, ondansetron hydrochloride, per 1mg J2410 Injection, oxymorphone HCl, up to 1mg J2425 Injection, palifermin, 50 micrograms J2430 Injection, pamidronate disodium, per 30mg J2440 Injection, papaverine HCl, up to 60mg Injection, oxytetracycline HCl, up to 50mg (All NDC's inactive since J2460 10/03) J2469 Injection, palonosetron HCl, 25 mcg J2501 Injection, paricalcitol, 1 mcg J2503 Injection, pegaptanib sodium, 0.3 mg J2504 Injection, pegademase bovine, 25 IU

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 17 of 35 Prior Authorization Code Description Required J2505 Injection, pegfilgrastim, 6mg J2510 Injection, penicillin G procaine, aqueous, up to 600,000 units J2513 Injection, pentastarch, 10% solution, 100 ml J2515 Injection, pentobarbital sodium, per 50mg J2540 Injection, penicillin G potassium, up to 600,000 units J2543 Injection, piperacillin sodium/tazobactam sodium, 1 g/0.125 g Pentamidine isethionate, inhalation solution, per 300mg, J2545 administered through a DME J2550 Injection, promethazine HCl, up to 50mg J2560 Injection, phenobarbital sodium, up to 120mg J2562 INJECTION, PLERIXAFOR, 1 MG Yes J2590 Injection, oxytocin, up to 10 units J2597 Injection, desmopressin acetate, per 1mcg Injection, prednisolone acetate, up to 1ml (Code price is based on J2650 25 mg/mL) J2670 Injection, tolazoline HCl, up to 25mg (All NDC's inactive since 11/02) J2675 Injection, progesterone, per 50 mg J2680 Injection, fluphenazine decanoate, up to 25mg J2690 Injection, procainamide HCl, up to 1g J2700 Injection, oxacillin sodium, up to 250mg J2710 Injection, neostigmine methylsulfate, up to 0.5mg J2720 Injection, protamine sulfate, per 10mg J2724 Injection, protein C concentrate, intravenous, human, 10 IU Yes J2725 Injection, protirelin, per 250mcg J2730 Injection, pralidoxime chloride, up to 1g J2760 Injection, phentolamine mesylate, up to 5mg J2765 Injection, metoclopramide HCl, up to 10mg J2770 Injection, quinupristin/dalfopristin, 500mg J2778 Injection, ranibizumab, 0.1 mg J2780 Injection, ranitidine hydrochloride, 25mg J2783 Injection, rasburicase, 0.5mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 18 of 35 Prior Authorization Code Description Required J2785 Injection, regadenoson, 0.1 mg J2788 Injection, Rho d immune globulin, human, minidose, 50 mcg J2790 Injection, Rho d immune globulin, human, full dose, 300 mcg Injection, Rho(D) immune globulin (human), (Rhophylac), J2791 intramuscular or intravenous, 100 IU Injection, rho D immune globulin, intravenous, human, solvent J2792 detergent, 100 IU J2793 Injection, Rilonacept, 1 MG Yes J2794 Injection, risperidone, long acting, 0.5 mg J2795 Injection, ropivacaine hydrochloride, 1mg J2796 Injection, Romiplostim, 10 Micrograms Yes J2800 Injection, methocarbamol, up to 10mL J2805 Injection, sincalide, 5 micrograms J2810 Injection, theophylline, per 40mg. J2820 Injection, sargramostim (GM‐CSF), 50mcg J2850 Injection, secretin, synthetic, human, 1 microgram Injection, aurothioglucose, up to 50mg (All NDC's inactive from 6/02 J2910 to 11/05 ‐ product re‐released 11/05) Injection, sodium ferric gluconate complex in sucrose injection, 12.5 J2916 mg J2920 Injection, methylprednisolone sodium succinate, up to 40mg J2930 Injection, methlprednisolone sodium succinate, up to 125mg J2940 Injection, somatrem, 1 mg (All NDC's inactive since 2/05) Yes J2941 Injection, somatropin, 1 mg Yes Injection, promazine HCl, up to 25mg (No active products currently J2950 on the market) J2993 Injection, reteplase, 18.1 mg J2995 Injection, streptokinase, per 250,000 IU J2997 Injection, alteplase recombinant, 1mg J3000 Injection, streptomycin, up to 1g J3010 Injection, fentanyl citrate, 0.1mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 19 of 35 Prior Authorization Code Description Required Injection, sumatriptan, succinate, 6mg (code may be used for Medicare when drug administered under direct supervision of a J3030 physician; not for use when drug is self‐administered) J3070 Injection, pentazocine, 30 mg J3101 Injection, tenecteplase, 1 mg J3105 Injection, terbutaline sulfate, up to 1mg J3110 Injection, teriparatide, 10 mcg J3120 Injection, testosterone enanthate, up to 100mg J3130 Injection, testosterone enanthate, up to 200mg Injection, testosterone suspension, up to 50mg (All NDC's inactive J3140 since 12/01) J3150 Injection, testosterone propionate, up to 100mg J3230 Injection, chlorpromazine HCl, up to 50mg J3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial J3243 Injection, tigecycline, 1 mg J3246 Injection, tirofiban HCl, 0.25 mg J3250 Injection, trimethobenzamide HCl, up to 200mg J3260 Injection, tobramycin sulfate, up to 80mg J3265 Injection, torsemide, 10mg/mL Injection, thiethylperazine maleate, up to 10mg (All NDC's inactive J3280 since 8/02) J3285 Injection, treprostinil, 1 mg Yes J3300 Injection, triamcinolone acetonide, preservative free, 1 mg Injection, triamcinolone acetonide, not otherwise specified, per J3301 10mg Injection, triamcinolone diacetate, per 5mg (All NDC's inactive since J3302 5/04) J3303 Injection, triamcinolone hexacetonide, per 5mg J3305 Injection, trimetrexate glucuronate, per 25mg J3310 Injection, perphenazine, up to 5mg (All NDC's inactive since 6/02) J3315 Injection, triptorelin pamoate, 3.75 mg J3320 Injection, spectinomycin dihydrochloride, up to 2g J3350 Injection, urea, up to 40g (All NDC's inactive since 10/02) J3355 Injection, urofollitropin, 75 IU

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 20 of 35

Prior Authorization Code Description Required J3360 Injection, diazepam, up to 5mg J3364 Injection, urokinase, 5,000 IU vial J3365 Injection, IV, urokinase, 250,000 IU vial J3370 Injection, vancomycin HCl, 500mg J3396 Injection, verteporfin, 0.1 mg J3400 Injection, triflupromazine HCl, up to 20mg J3410 Injection, hydroxyzine HCl, up to 25mg J3411 Injection, thiamine HCl, 100mg J3415 Injection, pyridoxine HCl, 100mg J3420 Injection, vitamin B‐12 cyanocobalamin, up to 1,000mcg J3430 Injection, phytonadione (vitamin K) per 1mg J3465 Injection, voriconazole, 10mg J3470 Injection, hyaluronidase, up to 150 units Injection, hyaluronidase, ovine, preservative free, per 1 USP unit (up J3471 to 999 USP units) Injection, hyaluronidase, ovine, preservative free, per 1000 USP J3472 units J3473 Injection, hyaluronidase, recombinant, 1 USP unit J3475 Injection, magnesium sulfate, per 500mg J3480 Injection, potassium chloride, per 2mEq J3485 Injection, zidovudine, 10mg J3486 Injection, ziprasidone mesylate, 10mg J3487 Injection, zoledronic acid, 1 mg J3488 Injection, zoledronic acid (Reclast), 1 mg Yes J3490 Unclassified Drugs Yes J3520 Edetate disodium, per 150mg J3530 Nasal vaccine inhalation J3535 Drug administered through a metered dose inhaler J3570 Laetrile, amygdalin, vitamin B‐17 J3590 Unclassified biologics J7030 Infusion, normal saline solution, 1,000cc J7040 Infusion, normal saline solution, sterile (500ml = 1 unit)

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 21 of 35

Prior Authorization Code Description Required J7042 5% Dextrose/normal saline (500ml = 1 unit) J7050 Infusion, normal saline solution, 250cc J7060 5% Dextrose/water (500ml = 1 unit) J7070 Infusion, D5W, 1,000cc J7100 Infusion, dextran 40, 500ml J7110 Infusion, dextran 75, 500ml J7120 Ringer's lactate infusion, up to 1,000cc J7130 Hypertonic saline solution, 50 or 100 mEq, 20 cc vial INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) J7185 (XYNTHA), PER I.U. Yes Injection, antihemophilic factor VIII/von Willebrand factor complex J7186 (human), per factor VIII i.u. Injection, von Willebrand factor complex (Humate‐P), per IU vWF‐ J7187 RCO Yes J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 microgram Yes J7190 Factor VIII (antihemophilic factor [human]) per IU Yes J7191 Factor VIII (antihemophilic factor [porcine]) per IU Yes Factor VIII (antihemophilic factor [recombinant]) per IU, not J7192 otherwise specified Yes J7193 Factor IX (antihemophilic factor, purified, non‐recombinant) per IU Yes J7194 Factor IX, complex, per IU Yes J7195 Factor IX (antihemophilic factor, recombinant) per IU Yes J7197 Antithrombin III (human), per IU Yes J7198 Anti‐inhibitor, per IU Yes J7199 Hemophilia clotting factor, not otherwise classified Yes J7300 Intrauterine copper contraceptive. J7302 Levonorgestrel‐releasing intrauterine contraceptive system, 52 mg J7303 Contraceptive supply, hormone containing vaginal ring, each J7304 Contraceptive supply, hormone containing patch, each Levonorgestrel (contraceptive) implant system, including implants J7306 and supplies Etonogestrel (contraceptive) implant system, including implant and J7307 supplies

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 22 of 35

Prior Authorization Code Description Required Aminolevulinic acid HCl for topical administration, 20%, single unit J7308 dosage form (354 mg) J7310 Ganciclovir, 4.5mg, long‐acting implant J7311 Fluocinolone acetonide, intravitreal implant Hyaluronan or derivative, Hyalgan or Supartz, for intra‐articular J7321 injection, per dose Yes Hyaluronan or derivative, Euflexxa, for intra‐articular injection, per J7323 dose Yes Hyaluronan or derivative, Orthovisc, fro intra‐articular injection, per J7324 dose Yes HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC‐ONE, FOR J7325 INTRA‐ARTICULAR NJECTION, 1 MG Yes J7330 Autologous cultured chondrocytes, implant J7500 Azathioprine, oral, 50 mg J7501 Azathioprine, parenteral, 100mg Yes J7502 Cyclosporine, oral, 100mg Lymphocyte immune globulin, antithymocyte globulin, equine, J7504 parenteral, 250 mg J7505 Muromonab‐CD3, parenteral, 5mg Yes J7506 Prednisone, oral, per 5mg J7507 Tacrolimus, oral, per 1mg J7509 Methylprednisolone, oral, per 4mg J7510 Prednisolone, oral, per 5mg Lymphocyte immune globulin, antithymocyte globulin, rabbit, J7511 parenteral, 25 mg J7513 Daclizumab, parenteral, 25mg Yes J7515 Cyclosporine, oral, 25mg J7516 Cyclosporine, parenteral, 250mg Yes J7517 Mycophenolate mofetil, oral, 250mg J7518 Mycophenolic acid, oral, 180 mg J7520 Sirolimus, oral, 1mg J7525 Tacrolimus, parenteral, 5mg Yes

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 23 of 35 Prior Authorization Code Description Required Acetylcysteine, inhalation solution, compunded product, J7604 administered through DME, unit dose form, per g Arformoterol, inhalation solution, FDA approved final product, noncompounded, administered through DME, unit dose form, 20 J7605 mcg Formoterol fumarate, inhalation solution, FDA approved final product, noncompounded, administered through DME, unit dose J7606 form, 20 mcg Levalbuterol, inhalation solution, compounded product, J7607 administered through DME, concentrated form, 0.5 mg Acetylcysteine, inhalation solution administered through DME, unit No ‐ Modifier J7608 dose form, per gram. Requirement Albuterol, inhalation solution, compounded product, administered J7609 through DME, unit dose, 1 mg Albuterol, inhalation solution, compounded product, administered J7610 through DME, concentrated for, 1 mg Albuterol, inhalation solution, administered through DME, J7611 concentrated form, 1 mg Levalbuterol, inhalation solution, administered through DME, J7612 concentrated form, 0.5 mg Albuterol, inhalation solution, administered through DME, unit J7613 dose, 1 mg Levalbuterol, inhalation solution, administered through DME, unit J7614 dose, 0.5 mg Levalbuterol, inhalation solution, compounded product, J7615 administered through DME, unit dose, 0.5 mg Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA‐approved final product, noncompunded, administered through J7620 DME Beclomethasone, inhalation solution, compounded product, No ‐ Modifier J7622 administeed through DME, unit dose form, per mg Requirement Betamethasone, inhalation solution, compounded product, No ‐ Modifier J7624 administered through DME, unit dose form, per mg Requirement

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 24 of 35 Prior Authorization Code Description Required Budesonide inhalation solution, non‐compounded, administered No ‐ Modifier J7626 through DME, unit dose form, up to 0.5 mg Requirement Budesonide, inhalation solution, compounded product, J7627 administered through DME, unit dose form, up to 0.5 mg Bitolterol mesylate, inhalation solution administered through DME, J7628 concentrated form, per milligram (All NDC's inactive since 6/02) Bitolterol mesylate, inhalation solution, compounded product, J7629 administered through DME, unit does form, per mg Cromolyn sodium, inhalation solution administered through DME, No ‐ Modifier J7631 unit‐dose form, per 10 milligrams Requirement Cromoly sodium, inhalation solution, compounded product, J7632 administered through DME, unit dose form, per 10 mg Budesonide, inhalation solution, FDA‐approved final product, noncompounded, administered through DME, concentrated form, J7633 per 0.25 mg Budesonide, inhalation solution, compounded product, J7634 administered through DME, concentrated form, per 0.25 mg Atropine, inhalation solution, compounded product, administered J7635 through DME, concentrated form, per mg Atropine, inhalation solution, compounded product, administered No ‐ Modifier J7636 through DME, unit dose form, per mg Requirement Dexamethasone, inhalation solution, compounded product, J7637 administered through DME, concentrated form, per mg Dexamethasone, inhalation solution, compounded product, J7638 administered through DME, unit dose form, per mg Dornase alpha, inhalation solution administered through DME, unit‐ No ‐ Modifier J7639 dose form, per milligram. Requirement Formoterol, inhalation solution, compounded product, adminstered J7640 through DME, unit dose form, 12 mcg Flunisolide, inhalation solution, compounded product, administered J7641 through DME, unit dose, per mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 25 of 35 Prior Authorization Code Description Required Glycopyrrolate, inhalation solution, compounded product, Yes (in school or J7642 administered through DME, concentrated form, per mg home setting) Glycopyrrolate, inhalation solution administered through DME, unit‐ No ‐ Modifier J7643 dose form, per milligram.(Further Documentation Requested) Requirement Ipratropium bromide, inhalation solution administered through No ‐ Modifier J7644 DME, unit‐dose form, per milligram. Requirement Ipratropium bromide, inhalation solution, compounded product, J7645 administered through DME, unit dose form, per mg Isoetharine HCI, inhalation solution, compounded product, J7647 administered through DME, concentrated form, per mg Isoetharine HCl, inhalation solution administered through DME, J7648 concentrated form, per milligram Isoetharine HCl, inhalation solution administered through DME, No ‐ Modifier J7649 unit‐dose form, per milligram Requirement Isoetharine HCI, inhalation solution, compounded product, J7650 administered through DME, unit dose form, per mg Isoproterenol HCI, inhalation solution, compounded product, J7657 administered through DME, concentrated form, per mg Isoproterenol HCI, inhalation solution, FDA‐approved final product, noncompounded, administered through DME, concentrated form, J7658 per mg Isoproterenol HCI, inalation solution, FDA‐approved final product, noncompounded, administered through DME, unit dose form, per No ‐ Modifier J7659 mg Requirement Isoproterenol HCI, inhalation solution, compounded product, J7660 administered through DME, unit dose form, per mg Metaproterenol sulfate, inhalation solution, compounded product, J7667 concentrated form, per 10 mg Metaproterenol sulfate, inhalation solution administered through J7668 DME, concentrated form, per 10 milligrams. Metaproterenol sulfate, inhalation solution administered through No ‐ Modifier J7669 DME, unit‐dose form, per 10 milligrams. Requirement

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 26 of 35 Prior Authorization Code Description Required Metaproterenol sulfate, inhalation solution, compounded product, J7670 administered through DME , unit dose form, per 10 mg Methacholine chloride administered as inhalation solution through J7674 a nebulizer, per 1 mg Pentamidine isethionate, inhalation solution, compounded product, J7676 administered through DME, unit dose form, per 300 mg Terbutaline sulfate, inhalation solution, compounded product, J7680 administered through DME, concentrated form, per mg Terbutaline sulfate, inhalation solution, compounded product, No ‐ Modifier J7681 administered through DME, unit dose form, per mg Requirement Tobramycin, unit dose form, 300mg, inhalation solution, No ‐ Modifier J7682 administered through DME. Requirement Triamcinolone, inhalation solution, compounded product, J7683 administered through DME, concentrated form, per mg Triamcinolone, inhalation solution, compounded product, No ‐ Modifier J7684 administered through DME, unit dose form, per mg Requirement Tobramycin, unhalation solution, compounded product, J7685 administered through DME, unit dose form, per 300 mg J7699 NOC drugs, inhalation solution administerd through DME J7799 NOC drugs, other than inhalation drugs, administerd through DME J8498 Antiemetic drug, rectal/suppository, not otherwise specified J8499 Prescription drug, oral, nonchemotherapeutic, NOS Yes J8501 Aprepitant, oral, 5 mg J8510 Busulfan, oral, 2mg J8515 Cabergoline, oral, 0.25 mg J8520 Capecitabine, oral, 150mg J8521 Capecitabine, oral, 500mg J8530 Cyclophosphamide, oral, 25mg J8540 Dexamethasone, oral, 0.25 mg J8560 Etoposide, oral, 50mg J8565 Gefitinib, oral, 250 mg J8597 Antiemetic drug, oral, not otherwise specified J8600 Melphalan, oral, 2mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 27 of 35 Prior Authorization Code Description Required J8610 Methotrexate, oral, 2.5mg J8650 Nabilone, oral, 1 mg Yes J8700 Temozolomide, oral, 5 mg J8705 Topotecan, oral, 0.25 mg J8999 Prescription drug, oral, chemotherapeutic, NOS J9000 Doxorubicin HCl, 10mg J9001 Doxorubicin hydrochloride, all lipid formulations, 10mg J9010 Alemtuzumab, 10 mg J9015 Aldesleukin, per single‐use vial J9017 Arsenic trioxide, 1 mg (Trisenox) J9020 Asparaginase, 10,000 units J9025 Injection, azacitidine, 1 mg J9027 Injection, clofarabine, 1 mg J9031 bCG (intravesical), per installation J9033 Injection, bendamustine HCI, 1 mg J9035 Injection, bevacizumab, 10 mg J9040 Bleomycin sulfate, 15 units J9041 Injection, bortezomib, 0.1 mg J9045 Carboplatin, 50mg J9050 Carmustine, 100mg J9055 Injection, cetuximab, 10 mg J9060 Cisplatin, powder or solution, per 10mg J9062 Cisplatin, 50mg J9065 Injection, cladribine, per 1mg J9070 Cyclophosphamide, 100mg J9080 Cyclophosphamide, 200mg J9090 Cyclophosphamide, 500mg J9091 Cyclophosphamide, 1.0g J9092 Cyclophosphamide, 2.0g J9093 Cyclophosphamide, lyophilized, 100mg J9094 Cyclophosphamide, lyophilized, 200mg J9095 Cyclophosphamide, lyophilized, 500mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 28 of 35 Prior Authorization Code Description Required J9096 Cyclophosphamide, lyophilized, 1.0g J9097 Cyclophosphamide, lyophilized, 2.0g J9098 Cytarabine liposome, 10 mg J9100 Cytarabine, 100mg J9110 Cytarabine, 500mg J9120 Dactinomycin, 0.5mg J9130 Dacarbazine, 100 mg J9140 Dacarbazine, 200mg J9150 Daunorubicin, 10mg J9151 Daunorubicin citrate, liposomal formulation, 10mg J9155 Injection, Degarelix, 1 MG Yes J9160 Denileukin diftitox, 300mcg Diethylstilbestrol diphosphate, 250mg (No longer commercially J9165 available in the US) J9171 Injection, Docetaxel, 1 MG J9175 Injection, Elliotts' B solution, 1 ml J9178 Injection, epirubicin HCl, 2 mg J9181 Etoposide, 10mg J9185 Fludarabine phosphate, 50mg J9190 Fluorouracil, 500mg J9200 Floxuridine, 500mg J9201 Gemcitabine HCl, 200mg J9202 Goserelin acetate implant, per 3.6mg Yes J9206 Irinotecan, 20mg J9207 Injection, Ixabepilone, 1 mg J9208 Ifosfamide, 1g J9209 Mesna, 200mg J9211 Idarubicin hydrochloride, 5mg J9212 Injection, interferon Alfacon‐1, recombinant, 1mcg Yes J9213 Interferon, alfa‐2a, recombinant, 3 million units J9214 Interferon, alfa‐2b, recombinant, 1 million units

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 29 of 35 Prior Authorization Code Description Required J9215 Interferon, alfa‐n3, (human leukocyte derived), 250,000 IU Yes J9216 Interferon, gamma 1‐b, 3 million units J9217 Leuprolide acetate (for depot suspension), 7.5mg Yes J9218 Leuprolide acetate, per 1mg Yes J9219 Leuprolide acetate implant, 65mg Yes J9225 Histrelin implant, 50 mg Yes J9226 Histrelin implant (Supprelin LA), 50 mg Yes J9230 Mechlorethamine hydrochloride, (nitrogen mustard), 10mg J9245 Injection, melphalan hydrochloride, 50mg J9250 Methotrexate sodium, 5mg J9260 Methotrexate sodium, 50mg J9261 Injection, nelarabine, 50 mg J9263 Injection, oxaliplatin, 0.5 mg Injection, paclitaxel protein‐bound particles, 1 mg (Code not J9264 effective for billing Medicare until 1/1/06) J9265 Paclitaxel, 30mg J9266 Pegaspargase, per single dose vial J9268 Pentostatin, per 10mg J9270 Plicamycin, 2.5mg J9280 Mitomycin, 5mg J9290 Mitomycin, 20mg J9291 Mitomycin, 40mg J9293 Injection, mitoxantrone hydrochloride, per 5mg J9300 Gemtuzumab ozogamicin, 5 mg J9303 Injection, panitumumab, 10 mg J9305 Injection, pemetrexed, 10 mg Yes for Diagnosis codes J9310 Rituximab, 100mg 714.0‐714.4 J9320 Streptozocin, 1g J9328 Injection, Temozolomide, 1 MG J9330 Injection, temsirolimus, 1 mg J9340 Thiotepa, 15mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 30 of 35 Prior Authorization Code Description Required J9350 Topotecan, 4mg J9355 Trastuzumab, 10mg J9357 Valrubicin, intravesical, 200mg (All NDC's inactive since 2/04) J9360 Vinblastine sulfate, 1mg J9370 Vincristine sulfate, 1mg J9375 Vincristine sulfate, 2mg J9380 Vincristine sulfate, 5mg J9390 Vinorelbine tartrate, per 10mg J9395 Injection, fulvestrant, 25 mg J9600 Porfimer sodium, 75mg P9041 Infusion, albumin (human), 5%, 50 mL P9043 Infusion, plasma protein fraction (human), 5%, 50 mL P9044 Plasma, cryoprecipitate reduced, each unit P9045 Infusion, albumin (human), 5%, 250 mL P9046 Infusion, albumin (human), 25%, 20 mL P9047 Infusion, albumin (human), 25%, 50 mL P9048 Infusion, plasma protein fraction (human), 5%, 250 mL P9050 Granulocytes, pheresis, each unit INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY Q0138 ANEMIA, 1 MG (NON‐ESRD USE) INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY Q0139 ANEMIA, 1 MG (For ESRD USE)

Diphenhydramine hydrochloride, 50mg oral, FDA‐approved prescription anti‐emetic, for use as a complete therapeutic substitute for an IV anti‐emetic at time of chemotherapy treatment, Q0163 not to exceed a 48‐hour dosage regimen (Code Price is per 50 mg) Dronabinol, 5mg 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 Q0168 regimen (Code price is per 5 mg effective 5/31/01)

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 31 of 35 Prior Authorization Code Description Required Promethazine hydrochloride, 25mg 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‐ Q0170 hour dosage regimen (Code price is per 25 mg) Chlorpromazine hydrochloride, 10mg 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 (Code Price is per 10 mg Q0171 tablet) Chlorpromazine hydrochloride, 25mg 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 (Code Price is per 25 mg Q0172 tablet) Thiethylperazine maleate, 10mg, 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‐ Q0174 hour dosage regimen (Code Price is per 10 mg) Perphenazine, 4mg, oral, FDA‐approved prescription anti‐emetic, for use as a complete therapeutic substitute for an IV anti‐emetic at time of chemotherapy threatment, not to exceed a 48‐hour dosage Q0175 regimen Perphenazine, 8mg, 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 Q0176 regimen Hydroxyzine pamoate, 50mg, 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 Q0178 dosage regimen (indication not FDA‐approved at this time Ondansetron hydrochloride 8mg, 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‐ Q0179 hour dosage regimen (Code price is per 8 mg)

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 32 of 35 Prior Authorization Code Description Required

Yes ‐ Available only through specialty pharmacy Q0515 Injection, sermorelin acetate, 1 microgram vendor Irrigation solution for treatment of bladder calculi, for example Q2004 renacidin, per 500mL Q2009 Injection, fosphenytoin, 50mg Q2017 Injection, teniposide, 50mg

Q2025 Fludarabine phosphate, oral, 1 MG Q2026 Injection, Radiesse, 0.1 ML Yes

Not a Covered Q2027 INJECTION, SCULPTRA, 0.1 ML Benefit Injection, interferon beta‐1A, 11 mcg for intramuscular use. (See Q3025 also J1825) Q3026 Injection, interferon beta‐1A, 11mcg for subcutaneous use. ILOPROST, INHALATION SOLUTION, FDA‐APPROVED FINAL PRODUCT, NON‐COMPOUNDED, ADMINISTERED THROUGH DME, Q4074 UNIT DOSE FORM, UP TO 20 MICROGRAMS Yes Q9954 Oral magnetic resonance contrast agent, per mL Q9955 Injection, perflexane lipid microspheres, per mL Injection, octafluoropropane microspheres, per mL (December 2005 Q9956 ‐ product temporarily unavailable) Q9957 Injection, perflutren lipid microspheres, per mL Injection, nonradioactive, noncontrast, visualization, adjunct (e.g. Q9968 methylene blue, isosulfan blue S0012 Butorphanol tartrate, nasal spray, 25mg S0014 Tacrine hydrochloride, 10mg

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 33 of 35 Prior Authorization Code Description Required S0017 Injection, aminocaproic acid, 5g Injection, bupivacaine hydrochloride, 30mL (0.5% 30 mL solution S0020 used to calculate the code price) S0021 Injection, cefoperazone sodium, 1g (All NDC's inactive since 1/03) S0023 Injection, cimetidine hydrochloride, 300mg S0028 Injection, famotidine, 20mg S0030 Injection, metronidazole, 500mg S0032 Injection, nafcillin sodium, 2g S0034 Injection, ofloxacin, 400mg (All NDC's inactive since 4/00) S0039 Injection, sulfamethoxazole and trimethoprim, 10mL S0040 Injection, ticarcillin disodium and clavulanate potassium, 3.1g S0073 Injection, aztreonam, 500mg S0074 Injection, cefotetan disodium, 500mg S0077 Injection, clindamycin phosphate, 300mg S0078 Injection, fosphenytoin sodium, 750mg S0080 Injection, pentamidine isethionate, 300mg S0081 Injection, piperacillin sodium, 500mg S0088 Imatinib 100mg Granisetron hydrochloride, 1 mg (for circumstances falling under S0091 the Medicare statute, use Q0166) Injection, hydromorphone HCl, 250mg (loading dose for infusion S0092 pump) S0093 Injection, morphine sulfate, 500mg (loading dose for infusion pump) S0104 Zidovudine, oral, 100 mg S0108 Mercaptopurine, oral, 50 mg S0109 Methadone, oral, 5 mg Yes ‐ Available only through specialty pharmacy S0145 Injection, pegylated interferon alfa‐2a, 180 mcg per mL vendor

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 34 of 35 Prior Authorization Code Description Required

Yes ‐ Available only through specialty Injection, pegylated interferon alfa‐2b, 10 mcg per 0.5 mL (Code pharmacy S0146 Price is per 10 mcg) vendor S0156 Exemestane, 25mg S0157 Becaplermin gel, 0.01%, 0.5g S0164 Injection, pantoprazole sodium, 40mg S0166 Injection, olanzapine, 2.5 mg

S0170 Anastrozole, oral, 1 mg

S0171 Injection, bumetanide, 0.5 mg S0172 Chlorambucil, oral, 2 mg Dolasetron mesylate, oral 50 mg (for circumstances falling under the S0174 Medicare statute, use Q0180) Yes Ondansetron HCl, oral, 4 mg (for circumstances falling under the S0181 Medicare statute, use Q0179) Yes S0182 Procarbazine HCl, oral, 50 mg Prochlorperazine maleate, oral, 5 mg (for circumstances falling S0183 under the Medicare statute, use Q0164 ‐ Q0165) S0189 Testosterone pellet, 75 mg Yes S0190 Mifepristone, oral, 200mg S0191 Misoprostol, oral, 200mcg Pneumococcal conjugate vaccine, polyvalent, intramuscular, for children from five years to nine years of age who have not S0195 previously received the vaccine (Code price is per 0.5 mL dose) S8490 Insulin syringes (100 syringes, any size)

Updated August 2010

This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA.

Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 35 of 35