BCBSIL Medicaid: Specialty Pharmacy Code List

Therapeutic Category Code Brand Drug Code Description Immune modulators C9293 VoraXaze Injection, glucarpidase, 10 units Injection, abatacept, 10 mg (code may be used for medicare when drug administered J0129 Orencia under the direct supervision of a physician, not for use when drug is self administered) J0178 Eylea Injection, aflibercept, 1 mg

Lysosomal storage disorders J0180 Fabrazyme Injection, agalsidase beta, 1 mg

Multiple sclerosis J0202 Lemtrada Injection, alemtuzumab, 1 mg J0220 Myozyme Injection, alglucosidase alfa, 10 mg, not otherwise specified J0221 Lumizyme Injection, alglucosidase alfa, (lumizyme), 10 mg Alpha-1 antitrypsin deficiency J0256 Aralast, Zemaira Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg J0257 Glassia Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg Other J0364 Apokyn Injection, apomorphine hydrochloride, 1 mg Lupus J0490 Benlysta Injection, belimumab, 10 mg Spacticity disorder J0585 BotoX Injection, onabotulinumtoXina, 1 unit J0586 Dysport Injection, abobotulinumtoXina, 5 units J0587 Myobloc Injection, rimabotulinumtoXinb, 100 units J0588 Xeomin Injection, incobotulinumtoXin a, 1 unit Heriditary angioedema J0596 Ruconest Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units J0597 Berinert Injection, c-1 esterase inhibitor (human), berinert, 10 units J0598 Cinryze Injection, c-1 esterase inhibitor (human), cinryze, 10 units CAPS J0638 Ilaris Injection, canakinumab, 1 mg J0775 XiafleX Injection, collagenase, clostridium histolyticum, 0.01 mg J0885 Procrit, Epogen Injection, epoetin alfa, (for non-esrd use), 1000 units J0890 Omontys Injection, peginesatide, 0.1 mg (for esrd on dialysis) J0897 Xgeva, Prolia Injection, denosumab, 1 mg J1290 Kalbitor Injection, ecallantide, 1 mg PNH J1300 Soliris Injection, eculizumab, 10 mg J1322 Vimizim Injection, elosulfase alfa, 1 mg Pulmonary arterial J1325 Epoprostenol Injection, epoprostenol, 0.5 mg hypertension

Last Updates: 04/05/2018 Therapeutic Category Code Brand Drug Code Description Hematopoietics J1442 Neupogen Injection, filgrastim (g-csf), eXcludes biosimilars, 1 microgram J1447 GraniX Injection, tbo-filgrastim, 1 microgram J1458 Naglazyme Injection, galsulfase, 1 mg J1459 Privigen Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg J1556 Bivigam Injection, immune globulin (bivigam), 500 mg Injection, immune globulin, (gammapleX), intravenous, non-lyophilized (e.g., liquid), 500 J1557 GammapleX mg J1559 Hizentra Injection, immune globulin (hizentra), 100 mg J1560 Gamastan Injection, gamma globulin, intramuscular, over 10 cc Injection, immune globulin, (gamuneX-c/gammaked), non-lyophilized (e.g., liquid), 500 J1561 GamuneX, Gammaked mg Carimune NF Panglobulin NF Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise J1566 Gammagard SD specified, 500 mg J1568 Octagam Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg

J1569 Gammagard non-lypholized Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized J1572 Flebogamma (e.g., liquid), 500 mg J1575 Hyqvia Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin J1743 Elaprase Injection, idursulfase, 1 mg j1744 Firazyr Injection, icatibant, 1 mg J1786 Cerezyme Injection, imiglucerase, 10 units Growth disorder J1930 Somatuline Injection, lanreotide, 1 mg J1931 Aldurazyme Injection, laronidase, 0.1 mg J2315 Vivitrol Injection, naltreXone, depot form, 1 mg J2323 Tysabri Injection, natalizumab, 1 mg J2353 Sandostatin Injection, octreotide, depot form for intramuscular injection, 1 mg J2354 Sandostatin Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg J2355 Neumega Injection, oprelvekin, 5 mg J2502 Signifor Injection, pasireotide long acting, 1 mg J2503 Macugen Injection, pegaptanib sodium, 0.3 mg J2504 Adagen Injection, pegademase bovine, 25 iu Gout J2507 KrysteXXa Injection, pegloticase, 1 mg J2778 Lucentis Injection, ranibizumab, 0.1 mg J2793 Arcalyst Injection, rilonacept, 1 mg ITP J2796 Nplate Injection, romiplostim, 10 micrograms J2820 Leukine Injection, sargramostim (gm-csf), 50 mcg

Last Updates: 04/05/2018 Therapeutic Category Code Brand Drug Code Description J3060 Elelyso Injection, taliglucerace alfa, 10 units J3262 Actemra Injection, tocilizumab, 1 mg J3285 Remodulin Injection, treprostinil, 1 mg J3380 Entyvio Injection, vedolizumab, 1 mg J3385 Vpriv Injection, velaglucerase alfa, 100 units J3396 Visudyne Injection, verteporfin, 0.1 mg J3489 Zoledronic Acid Injection, zoledronic acid, 1 mg J7311 Retisert Fluocinolone acetonide, intravitreal implant J7312 OzurdeX Injection, deXamethasone, intravitreal implant, 0.1 mg J7313 Iluvien Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg J7316 Jetrea Injection, ocriplasmin, 0.125 mg Osteoarthritis J7321 Hyalgan, Supartz Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose J7323 EufleXXa Hyaluronan or derivative, eufleXXa, for intra-articular injection, per dose J7324 Dacarbazine Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose J7325 Dacarbazine Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg J7326 Gel-one hyaluronan Hyaluronan or derivative, gel-one, for intra-articular injection, per dose J7327 Monovisc Hyaluronan or derivative, monovisc, for intra-articular injection, per dose Dornase alfa, inhalation solution, fda-approved final product, non-compounded, Cystic fibrosis J7639 Pulmozyme administered through dme, unit dose form, per milligram Tobramycin, inhalation solution, fda-approved final product, non-compounded, unit dose J7682 Bethkis, Kitabis, Tobi form, administered through dme, per 300 milligrams Infectious Disease J9215 Alferon N Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iu J9216 Actimmune Injection, interferon, gamma 1-b, 3 million units Hormonal therapy J9226 Supprelin LA Histrelin implant (supprelin la), 50 mg J9293 Novantrone Injection, mitoXantrone hydrochloride, per 5 mg J9310 RituXan Injection, rituXimab, 100 mg Q4081 Procrit, Epogen Injection, epoetin alfa, 100 units (for esrd on dialysis) Q9973 Mircera for non-ESRD Injection, epoetin beta, 1 microgram, (non-esrd use) Q9980 Genvisc Hyaluronan or derivative, genvisc 850, for intra-articular injection, 1 mg Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin); administrative S9346 Prolastin services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, enzyme replacement intravenous therapy; (e.g., imiglucerase); S9357 Cerezyme administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home injectable therapy, palivizumab, including administrative services, professional S9562 Synagis pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem CPT® copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Last Updates: 04/05/2018