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List of Drugs That Are Included in the Program

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List of Drugs That Are Included in the Program MEDICAL INJECTABLE DRUG PROGRAM EFFECTIVE 09/01/2021 (additions in red) Brand Name Generic Name (billing code description) HCPCS MID Voluntary Adcetris brentuximab vedotin J9042 Alimta pemetrexed J9305 Avastin bevacizumab J9035 Erbitux cetuximab J9055 Eylea afilbercept J0178 Faslodex fulvestrant J9395 Halaven eribulin J9179 Kadcyla ado-trastuzumab emtansine J9354 Kyprolis carfilzomib J9047 Lucentis ranibizumab injection J2778 Macugen pegaptanib sodium J2503 Nplate romiplostim J2796 Oncaspar pegaspargase J9266 Opdivo nivolumab J9299 Perjeta pertuzumab J9306 Rituxan rituximab J9312 Treanda bendamustine J9033 Valstar valrubicin J9357 Velcade bortezomib J9041 Yervoy ipilimumab J9228 MID Mandatory Actimmune interferon gamma-1b J9216 Adagen pegademase bovine J2504 Aldurazyme laronidase J1931 Benlysta belimumab J0490 Betaseron interferon beta-1b J1830 Bivigam (immune globulin intravenous [human]) J1556 Botox botulinum toxin type A J0585 Carimune NF IVIG [immune globulin] (lyophilized and non-lyophilized) J1566 Cerezyme imiglucerase J1786 Copaxone glatiramer acetate J1595 Cosentyx secukinumab J3590 Durolane (preferred) hyaluronic acid J7318 Dysport abobotulinumtoxia A J0586 Elaprase idursulfase J1743 Enytivo vedolizumab J3380 Euflexxa (preferred) hyaluronate sodium injection J7323 Extavia interferon beta-1b J1830 Fabrazyme agalsidase beta J0180 Flebogamma DIF Injection, immune globulin, (flebogamma/flebogamma dif), J1572 intravenous, non-lyophilized (e.g. liquid), 500 mg Forteo teriparatide J3110 Gammagard immune globulin J1569 Gammagard S/D IVIG [immune globulin] (lyophilized and non-lyophilized) J1566 Gammaplex immune globulin J1557 Gamunex immune globulin J1561 Gamunex-C immune globulin Intravenous (Human) J1561 1 Brand Name Generic Name (billing code description) HCPCS MID Mandatory Gel-One hyaluronate hydrogel J7326 GELSYN-3 (preferred) sodium hyaluronate J7328 Genotropin somatropin [rDNA origin] J2941 GenVisc 850 sodium hyaluronate J7320 Glatopa glatiramer acetate J1595 H.P. Acthar repository corticotrophin J0800 Hizentra immune globulin [human] J1559 Humatrope somatropin [rDNA origin] J2941 Hyalgan sodium hyaluronate J7321 Hydroxyprogesterone Caproate (HPC) hydroxyprogesterone caproate J1729 Hymovis hyaluronan J7322 HyQvia Recombinant Human Hyaluronidase J1575 Ilaris canakinumab J0638 IVIG immune globulin [human] 90283 Kanuma sebelipase alfa J2840 Lemtrada alemtuzumab J0202 Lumizyme alglucosidase alfa J0221 Makena hydroxyprogesterone J1726 Monovisc high molecular weight hyaluronan J7327 Myobloc botulinum toxin type B J0587 Natpara parathyroid hormone J3590 Norditropin Growth Hormone J2941 Nucala mepolizumab J2182 Nutropin Growth Hormone J2941 Ocrevus ocrelizumab J2350 Octagam immune globulin J1568 Omnitrope somatropin J2941 Orencia abatacept J0129 Orthovisc high molecular weight hyaluronan J7324 Plegridy peginterferon beta-1a J3590 Praluent alirocumab J3590 Prialt ziconotide intrathecal infusion J2278 Privigen immune globulin [human] J1459 Rebif interferon beta-1a Q3028 Repatha evolocumab J3590 Risperdal Consta risperidone J2794 Ruconest recombinant human C1 esterase inhibitor (rhC1INH) J0596 Saizen [somatropin (rDNA origin)] J2941 Serostim somatropin J2941 Soliris eculizumab J1300 Stelara ustekinumab J3357 Stelara IV ustekinumab J3358 Supartz FX (preferred) sodium hyaluronate J7321 Supprelin LA histrelin acetate J9226 Sylvant siltuximab J2860 Synagis palivizumab 90378 Synvisc hylan GF 20 J7325 Synvisc- One hylan GF 20 J7325 Tev-Tropin [somatropin (rDNA origin)] J2941 Thyrogen thyrotropin alfa J3240 2 Brand Name Generic Name (billing code description) HCPCS MID Mandatory Tysabri natalizumab J2323 Visco-3 sodium hyaluronate J7333 Visudyne verteporfin J3396 Vivaglobin immune globulin subcutaneous J1562 & 90284 VPRIV veraglucerase J3385 Xeomin incobotulinumtoxin A J0588 Xolair omalizumab J2357 Zorbitive [somatropin (rDNA origin)] J2941 3.
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