NYS DOH - Never Pay Procedures Under APG Reimbursement Revised for January 1, 2017 Updates:

Information revised during the quarterly update period stated above is highlighted.

Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List 20696 Comp multiplane ext fixation No 01/01/13 20697 Comp ext fixate strut change No 01/01/13 20983 Ablate bone tumor(s) perq No 07/01/16 20985 Cptr‐asst dir ms px No 12/01/08 20986 Cptr‐asst dir ms px io img No 12/01/08 20987 Cptr‐asst dir ms px pre img No 12/01/08 22867 Insj stablj dev w/dcmprn TBD 01/01/17 22868 Insj stablj dev w/dcmprn TBD 01/01/17 22869 Insj stablj dev w/o dcmprn TBD 01/01/17 22870 Insj stablj dev w/o dcmprn TBD 01/01/17 27412 Autochondrocyte implant knee No 07/01/10 28890 High energy eswt, plantar f No 12/01/08 36473 Endovenous mchnchem 1st vein TBD 01/01/17 36474 Endovenous mchnchem add‐on TBD 01/01/17 43257 Uppr gi scope w/thrml txmnt No 07/01/10 43284 Laps esophgl sphnctr agmntj TBD 01/01/17 43285 Rmvl esophgl sphnctr dev TBD 01/01/17 55400 Repair of sperm duct No 04/01/13 55706 Prostate saturation sampling No 07/01/10 58750 Repair oviduct No 10/01/09 62380 Ndsc dcmprn 1 ntrspc lumbar TBD 01/01/17 70554 Fmri brain by tech No 12/01/08 74261 Ct colonography dx No 04/01/11 74262 Ct colonography dx w/dye No 04/01/11 74263 Ct colonography screening No 04/01/11 75571 Ct hrt w/o dye w/ca test No 04/01/11 75572 Ct hrt w/3d image No 04/01/11 75573 Ct hrt w/3d image congen No 04/01/11 75574 Ct angio hrt w/3d image No 04/01/11 07/01/16 77082 Dxa bone density vert fx No 10/01/12 77422 Neutron beam tx, simple No 04/01/09 07/01/10 77423 Neutron beam tx, complex No 04/01/09 07/01/10 81161 Dmd dup/delet analysis No 01/01/15 81200 Aspa gene Yes 01/01/16 81201 Apc gene full sequence Yes 01/01/16 81202 Apc gene known fam variants Yes 01/01/16 81203 Apc gene dup/delet variants Yes 01/01/16 81205 Bckdhb gene Yes 01/01/16 81206 Bcr/abl1 gene major bp Yes 01/01/16 81207 Bcr/abl1 gene minor bp Yes 01/01/16 81208 Bcr/abl1 gene other bp Yes 01/01/16 81209 Blm gene Yes 01/01/16 81210 Braf gene Yes 01/01/16 81211 Brca1&2 seq & com dup/del Yes 01/01/16 81212 Brca1&2 185&5385&6174 var Yes 01/01/16 81213 Brca1&2 uncom dup/del var No 01/01/16 81214 Brca1 full seq & com dup/del Yes 01/01/16 81215 Brca1 gene known fam variant Yes 01/01/16 81216 Brca2 gene full sequence Yes 01/01/16 81217 Brca2 gene known fam variant Yes 01/01/16 81220 Cftr gene com variants Yes 01/01/16 81221 Cftr gene known fam variants Yes 01/01/16 81222 Cftr gene dup/delet variants Yes 01/01/16 81223 Cftr gene full sequence Yes 01/01/16 81224 Cftr gene intron poly t Yes 01/01/16 81225 Cyp2c19 gene com variants No 01/01/16 81226 Cyp2d6 gene com variants Yes 01/01/16 81227 Cyp2c9 gene com variants No 01/01/16

Page 1 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List 81228 Cytogen micrarray copy nmbr Yes 01/01/16 81229 Cytogen m array copy no&snp Yes 01/01/16 81235 Egfr gene com variants Yes 01/01/16 81240 F2 gene Yes 01/01/16 81241 F5 gene Yes 01/01/16 81242 Fancc gene Yes 01/01/16 81243 Fmr1 gene detection Yes 01/01/16 81244 Fmr1 gene characterization Yes 01/01/16 81245 Flt3 gene Yes 01/01/16 81246 Flt3 gene analysis No 01/01/16 81250 G6pc gene Yes 01/01/16 81251 Gba gene Yes 01/01/16 81252 Gjb2 gene full sequence Yes 01/01/16 81253 Gjb2 gene known fam variants Yes 01/01/16 81254 Gjb6 gene com variants Yes 01/01/16 81255 Hexa gene Yes 01/01/16 81256 Hfe gene No 01/01/16 81257 Hba1/hba2 gene Yes 01/01/16 81260 Ikbkap gene Yes 01/01/16 81261 Igh gene rearrange amp meth No 01/01/16 81262 Igh gene rearrang dir probe No 01/01/16 81263 Igh vari regional mutation No 01/01/16 81264 Igk rearrangeabn clonal pop No 01/01/16 81265 Str markers specimen anal No 01/01/16 81266 Str markers spec anal addl No 01/01/16 81267 Chimerism anal no cell selec No 01/01/16 81268 Chimerism anal w/cell select No 01/01/16 81270 Jak2 gene No 01/01/16 81275 Kras gene Yes 01/01/16 81280 Long qt synd gene full seq Yes 01/01/16 81281 Long qt synd known fam var Yes 01/01/16 81282 Long qt syn gene dup/dlt var Yes 01/01/16 81287 Mgmt gene methylation anal Yes 01/01/16 81288 Mlh1 gene No 01/01/16 81290 Mcoln1 gene Yes 01/01/16 81291 Mthfr gene No 01/01/16 81292 Mlh1 gene full seq Yes 01/01/16 81293 Mlh1 gene known variants Yes 01/01/16 81294 Mlh1 gene dup/delete variant Yes 01/01/16 81295 Msh2 gene full seq Yes 01/01/16 81296 Msh2 gene known variants Yes 01/01/16 81297 Msh2 gene dup/delete variant Yes 01/01/16 81298 Msh6 gene full seq Yes 01/01/16 81299 Msh6 gene known variants Yes 01/01/16 81300 Msh6 gene dup/delete variant Yes 01/01/16 81301 Microsatellite instability Yes 01/01/16 81302 Mecp2 gene full seq Yes 01/01/16 81303 Mecp2 gene known variant Yes 01/01/16 81304 Mecp2 gene dup/delet variant Yes 01/01/16 81310 Npm1 gene Yes 01/01/16 81313 Pca3/klk3 antigen No 01/01/16 81315 Pml/raralpha com breakpoints Yes 01/01/16 81316 Pml/raralpha 1 breakpoint Yes 01/01/16 81317 Pms2 gene full seq analysis Yes 01/01/16 81318 Pms2 known familial variants Yes 01/01/16 81319 Pms2 gene dup/delet variants Yes 01/01/16 81321 Pten gene full sequence Yes 01/01/16 81322 Pten gene known fam variant Yes 01/01/16 81323 Pten gene dup/delet variant Yes 01/01/16 81324 Pmp22 gene dup/delet No 01/01/16 81325 Pmp22 gene full sequence No 01/01/16 81326 Pmp22 gene known fam variant No 01/01/16 81327 Sept9 methylation analysis TBD 01/01/17

Page 2 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List 81330 Smpd1 gene common variants Yes 01/01/16 81331 Snrpn/ube3a gene Yes 01/01/16 81332 Serpina1 gene Yes 01/01/16 81340 Trb@ gene rearrange amplify No 01/01/16 81341 Trb@ gene rearrange dirprobe No 01/01/16 81342 Trg gene rearrangement anal No 01/01/16 81350 Ugt1a1 gene Yes 01/01/16 81355 Vkorc1 gene Yes 01/01/16 81370 Hla i & ii typing lr No 01/01/16 81371 Hla i & ii type verify lr No 01/01/16 81372 Hla i typing complete lr No 01/01/16 81373 Hla i typing 1 locus lr No 01/01/16 81374 Hla i typing 1 antigen lr No 01/01/16 81375 Hla ii typing ag equiv lr No 01/01/16 81376 Hla ii typing 1 locus lr No 01/01/16 81377 Hla ii type 1 ag equiv lr No 01/01/16 81378 Hla i & ii typing hr No 01/01/16 81379 Hla i typing complete hr No 01/01/16 81380 Hla i typing 1 locus hr No 01/01/16 81381 Hla i typing 1 allele hr No 01/01/16 81382 Hla ii typing 1 loc hr No 01/01/16 81383 Hla ii typing 1 allele hr No 01/01/16 81400 Mopath procedure level 1 Yes 01/01/16 81401 Mopath procedure level 2 Yes 01/01/16 81402 Mopath procedure level 3 Yes 01/01/16 81403 Mopath procedure level 4 Yes 01/01/16 81404 Mopath procedure level 5 Yes 01/01/16 81405 Mopath procedure level 6 Yes 01/01/16 81406 Mopath procedure level 7 Yes 01/01/16 81407 Mopath procedure level 8 Yes 01/01/16 81408 Mopath procedure level 9 Yes 01/01/16 81410 Aortic dysfunction/dilation No 01/01/16 81411 Aortic dysfunction/dilation No 01/01/16 81415 Exome sequence analysis No 01/01/16 81416 Exome sequence analysis No 01/01/16 81417 Exome re‐evaluation No 01/01/16 81420 Fetal chrmoml aneuploidy Yes 01/01/16 81422 Fetal chrmoml microdeltj TBD 01/01/17 81425 Genome sequence analysis No 01/01/16 81426 Genome sequence analysis No 01/01/16 81427 Genome re‐evaluation No 01/01/16 81430 Hearing loss sequence analys No 01/01/16 81431 Hearing loss dup/del analys No 01/01/16 81435 Hereditary colon cancer No 01/01/16 81436 Hereditary colon ca synd No 01/01/16 81439 Inherited cardmypthy 5 gns TBD 01/01/17 81440 Mitochondrial gene No 01/01/16 81445 Targeted genomic seq analys No 01/01/16 81450 Targeted genomic seq analys No 01/01/16 81455 Targeted genomic seq analys No 01/01/16 81460 Whole mitochondrial genome No 01/01/16 81465 Whole mitochondrial genome No 01/01/16 81470 X‐linked intellectual dblt No 01/01/16 81471 X‐linked intellectual dblt No 01/01/16 81479 Unlisted molecular pathology Yes 01/01/16 81500 Onco (ovar) two proteins No 01/01/16 81503 Onco (ovar) five proteins No 01/01/16 81504 Oncology tissue of origin No 01/01/16 81506 Endo assay seven anal No 01/01/16 81507 Fetal aneuploidy trisom risk Yes 01/01/16 81508 Ftl cgen abnor two proteins Yes 01/01/16 81509 Ftl cgen abnor 3 proteins Yes 01/01/16 81510 Ftl cgen abnor three anal Yes 01/01/16

Page 3 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List 81511 Ftl cgen abnor four anal Yes 01/01/16 81512 Ftl cgen abnor five anal Yes 01/01/16 81519 Oncology breast mrna Yes 01/01/16 81539 Oncology prostate prob score TBD 01/01/17 81599 Unlisted maaa No 01/01/16 83655 Assay of lead Yes 12/01/08 83890 Molecule isolate Yes 01/01/10 83891 Molecule isolate nucleic Yes 01/01/10 83892 Molecular diagnostics Yes 01/01/10 83893 Molecule dot/slot/blot Yes 01/01/10 83894 Molecule gel electrophor Yes 01/01/10 83896 Molecular diagnostics Yes 01/01/10 83897 Molecule nucleic transfer Yes 01/01/10 83898 Molecule nucleic ampli, each Yes 01/01/10 83900 Molecule nucleic ampli 2 seq Yes 01/01/10 83901 Molecule nucleic ampli addon Yes 01/01/10 83902 Molecular diagnostics Yes 01/01/10 83903 Molecule mutation scan Yes 01/01/10 83904 Molecule mutation identify Yes 01/01/10 83905 Molecule mutation identify Yes 01/01/10 83906 Molecule mutation identify Yes 01/01/10 83907 Lyse cells for nucleic ext Yes 01/01/10 83908 Nucleic acid, signal ampli Yes 01/01/10 83909 Nucleic acid, high resolute Yes 01/01/10 83912 Genetic examination Yes 01/01/10 83913 Molecular, rna stabilization Yes 01/01/10 83914 Mutation ident ola/sbce/aspe Yes 01/01/10 84410 Testosterone bioavailable TBD 01/01/17 85004 Automated diff wbc count Yes 10/01/09 85610 Prothrombin time Yes 10/01/09 86849 Immunology procedure Yes 04/01/12 87483 Cns dna amp probe type 12‐25 TBD 01/01/17 87536 Hiv‐1, dna, quant Yes 12/01/08 87539 Hiv‐2, dna, quant No 04/01/10 87900 Virtual phenotype Yes 01/01/10 87901 GeNo ‐ APG Carve Outtype, dna, hiv reverse t Yes 12/01/08 87902 GeNo ‐ APG Carve Outtype, dna, hepatitis C Yes 12/01/08 87903 PheNo ‐ APG Carve Outtype, dna hiv w/culture Yes 12/01/08 87904 PheNo ‐ APG Carve Outtype, dna hiv w/clt add Yes 10/01/09 87999 Microbiology procedure Yes 12/01/08 88230 Tissue culture, lymphocyte Yes 01/01/10 88233 Tissue culture, skin/biopsy Yes 01/01/10 88235 Tissue culture, placenta Yes 01/01/10 88237 Tissue culture, bone marrow Yes 01/01/10 88239 Tissue culture, tumor Yes 01/01/10 88240 Cell cryopreserve/storage Yes 01/01/10 88241 Frozen cell preparation Yes 01/01/10 88245 Chromosome analysis, 20‐25 Yes 01/01/10 88248 Chromosome analysis, 50‐100 Yes 01/01/10 88249 Chromosome analysis, 100 Yes 01/01/10 88261 Chromosome analysis, 5 No 01/01/10 88262 Chromosome analysis, 15‐20 Yes 01/01/10 88263 Chromosome analysis, 45 Yes 01/01/10 88264 Chromosome analysis, 20‐25 No 01/01/10 88267 Chromosome analys, placenta Yes 01/01/10 88269 Chromosome analys, amniotic Yes 01/01/10 88271 Cytogenetics, dna probe Yes 01/01/10 88272 Cytogenetics, 3‐5 Yes 01/01/10 88273 Cytogenetics, 10‐30 Yes 01/01/10 88274 Cytogenetics, 25‐99 Yes 01/01/10 88275 Cytogenetics, 100‐300 Yes 01/01/10 88280 Chromosome karyotype study Yes 01/01/10 88283 Chromosome banding study No 01/01/10

Page 4 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List 88285 Chromosome count, additional Yes 01/01/10 88289 Chromosome study, additional No 01/01/10 88291 Cyto/molecular report Yes 01/01/10 88299 Cytogenetic study No 01/01/16 90470 H1N1 Administration Yes 10/01/09 07/01/11 90473 Immune admin oral/nasal Yes 10/01/09 04/01/11 90655 Flu vaccine no preserv 6‐35m Yes 10/01/09 04/01/11 90656 Flu vaccine no preserv 3 & > Yes 10/01/09 04/01/11 90657 Flu vaccine, 3 yrs, im Yes 10/01/09 04/01/11 90658 Flu vaccine, 3 yrs & >, im Yes 10/01/09 04/01/11 90660 Flu vaccine, nasal Yes 10/01/09 04/01/11 90663 Flu vacc pandemic Yes 10/01/09 07/01/11 90669 Pneumococcal vacc, ped <5 Yes 10/01/09 04/01/11 90732 Pneumococcal vaccine Yes 10/01/09 04/01/11 90750 Hzv vacc recombinant im njx TBD 01/01/17 90863 Pharmacologic mgmt w/psytx No 04/01/13 90875 Psychophysiological therapy No 07/01/10 90876 Psychophysiological therapy No 07/01/10 90880 Hypnotherapy No 04/01/09 90901 Biofeedback train, any meth No 07/01/10 90911 Biofeedback peri/uro/rectal No 07/01/10 92145 Corneal hysteresis deter No 07/01/16 93702 Bis xtracell fluid analysis No 07/01/16 93895 Carotid intima atheroma eval No 07/01/16 94664 Evaluate pt use of inhaler No 10/01/16 95012 Exhaled nitric oxide meas No 12/01/08 95800 Slp stdy unattended No 01/01/13 95801 Slp stdy unatnd w/anal No 01/01/13 95806 Sleep study unatt&resp efft No 01/01/13 95965 Meg, spontaneous No 12/01/08 07/01/16 95966 Meg, evoked, single No 12/01/08 07/01/16 96102 Psycho testing by technician No 04/01/09 04/01/10 96119 Neuropsych testing by tec No 04/01/09 04/01/10 96127 Brief emotional/behav assmt No 07/01/16 97012 Mechanical traction therapy No 04/01/13 97124 Massage therapy No 04/01/09 07/01/10 97150 Group therapeutic procedures No 04/01/09 04/01/10 97169 Athletic trn eval low cmplx TBD 01/01/17 97170 Athletic trn eval mod cmplx TBD 01/01/17 97171 Athletic trn eval high cmplx TBD 01/01/17 97172 Athletic trn re‐eval plan cr TBD 01/01/17 97610 Low frequency non‐thermal us No 07/01/16 97810 Acupunct w/o stimul 15 min No 04/01/09 97811 Acupunct w/o stimul addl 15m No 04/01/09 97813 Acupunct w/stimul 15 min No 04/01/09 97814 Acupunct w/stimul addl 15m No 04/01/09 98940 Chiropractic manipulation No 01/01/12 98941 Chiropractic manipulation No 04/01/11 98942 Chiropractic manipulation No 01/01/12 98943 Chiropractic manipulation No 01/01/12 99002 Device Handling No 04/01/11 0004M Scoliosis dna alys No 01/01/16 0006M Onc hep gene risk classifier No 01/01/16 0007M Onc gastro 51 gene nomogram No 01/01/16 0008M Onc breast risk score No 01/01/16 0009M Fetal aneuploidy trisom risk No 01/01/16 0010M Onc Prostate prob score No 01/01/16 0019T Extracorp shock wv tx,ms nos No 04/01/10 0126T Chd risk imt study No 01/01/13 0216T Njx paravert w/us lumb/sac No 01/01/13 0217T Njx paravert w/us lumb/sac No 01/01/13 0218T Njx paravert w/us lumb/sac No 01/01/13 0310T Motor function mapping ntms No 04/01/13

Page 5 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List 0311T Cal & alys cntrl artl press No 04/01/13 1000F Tobacco use assessed No 12/01/08 4000F Tobacco use txmnt counseling No 12/01/08 A4459 Manual pump enema, reusable No 07/01/16 C9137 Adynovate Factor VIII recom No 07/01/16 C9138 Nuwiq Factor VIII recomb No 07/01/16 C9259 Injection, pralatrexate, 1 mg Yes 01/01/11 C9287 Inj, brentuximab vedotin Yes 07/01/12 C9471 Hymovis, 1 mg No 07/01/16 C9716 Radiofrequency energy to anu No 07/01/10 D0414 Lab process microbial spec TBD 01/01/17 D0421 Gen tst suscept oral disease Yes 01/01/16 D0600 Non‐ionizing diag proc TBD 01/01/17 D1575 Dist space maint, fixed unil TBD 01/01/17 D4346 Scaling gingiv inflammation TBD 01/01/17 D6081 Scale & debride, single imp TBD 01/01/17 D6085 Provisional implant crown TBD 01/01/17 D9210 Dent anesthesia w/o surgery No 01/01/16 D9211 Regional block anesthesia No 01/01/16 D9212 Trigeminal block anesthesia No 01/01/16 D9215 Local anesthesia No 01/01/16 D9221 General anesthesia ea ad 15m No 07/01/11 D9242 IV sedation ea ad 30 m No 07/01/11 D9311 Consult w/med hlth care prof TBD 01/01/17 D9920 Behavior management, by report No 12/01/08 07/01/11 D9991 Case mgmt, appt barriers TBD 01/01/17 D9992 Case mgmt, care coordination TBD 01/01/17 D9993 Case mgmt, interviewing TBD 01/01/17 D9994 Case mgmt, pt education TBD 01/01/17 G0008 Admin influenza virus vac Yes 10/01/09 04/01/11 G0009 Admin pneumococcal vaccine Yes 10/01/09 04/01/11 G0398 Home sleep test/type 2 Porta No 01/01/13 G0399 Home sleep test/type 3 Porta No 01/01/13 G0400 Home sleep test/type 4 Porta No 01/01/13 G0464 Colorec ca scr, sto bas dna Yes 01/01/16 G0493 Rn care ea 15 min hh/hospice TBD 01/01/17 G0494 Lpn care ea 15min hh/hospice TBD 01/01/17 G0495 Rn care train/edu in hh TBD 01/01/17 G0496 Lpn care train/edu in hh TBD 01/01/17 G8402 Smoke preven interven counse No 12/01/08 G8403 Smoke preven Outcounsel No 12/01/08 G9016 Demo‐smoking cessation coun No 12/01/08 G9141 Influenza A (H1N1) ‐ administration No 10/01/09 07/01/11 G9142 Influenza A (H1N1) ‐ vaccine No 10/01/09 07/01/11 G9143 Warfarin respon genetic test Yes 01/01/16 G9481 Remote E/M new pt 10mins No 07/01/16 G9482 Remote E/M new pt 20mins No 07/01/16 G9483 Remote E/M new pt 30mins No 07/01/16 G9484 Remote E/M new pt 45mins No 07/01/16 G9485 Remote E/M new pt 60mins No 07/01/16 G9486 Remote E/M est. pt 10mins No 07/01/16 G9487 Remote E/M est. pt 15mins No 07/01/16 G9488 Remote E/M est. pt 25mins No 07/01/16 G9489 Remote E/M est. pt 40mins No 07/01/16 G9490 Joint replac mod home visit No 07/01/16 G9678 Oncology Care Model service No 07/01/16 H0018 Alcohol and/or drug services No 07/01/10 H0023 Behavioral health outreach service ‐ planned approach to No 10/01/10 reach a targeted population H0032 MH svc plan dev by non‐md No 07/01/10 H0037 Comm psy sup tx pgm per diem No 07/01/10 H2029 Sex offend tx svc, per diem No 07/01/10 J0128 Injection, abarelix, 10 mg Yes 01/01/11

Page 6 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List J0365 Injection, aprotonin, 10,000 kiu Yes 01/01/11 J0480 Injection, basiliximab, 20 mg Yes 01/01/11 J0585 Botulinum toxin a per unit Yes 12/01/08 01/01/15 J0587 Botulinum toxin type B Yes 12/01/08 J0740 Injection, cidofovir, 375 mg Yes 01/01/11 J0882 Darbepoetin alfa, esrd use Yes 12/01/08 01/01/12 J0886 Epoetin alfa 1000 units ESRD Yes 12/01/08 01/01/12 10/01/13 J0890 Peginesatide injection No 07/01/13 J1440 Filgrastim 300 mcg injection Yes 12/01/08 J1441 Filgrastim 480 mcg injection Yes 12/01/08 J1566 Injection, immune globulin, intravenous, lyophilized (e.g. Yes 01/01/11 J1675 Injection, histrelin acetate, 10 micrograms Yes 01/01/11 J1725 Hydroxyprogesterone caproate Yes 04/01/12 J1931 Injection, laronidase, 0.1 mg Yes 01/01/11 J2315 Naltrexone, depot form Yes ‐ Only for 01/01/10 07/01/11 Article 32 providers

J2323 Natalizumab injection Yes ‐ only for 01/01/10 TOUCH providers 01/01/11 J2358 Olanzapine long‐acting inj Yes 04/01/11 J2426 Paliperidone palmitate inj Yes 04/01/11 J2505 Injection, pegfilgrastim 6mg Yes 12/01/08 J2562 Injection, plerixafor, 1 mg Yes 01/01/11 J2794 Risperidone, long acting Yes 04/01/09 J2997 Alteplase recombinant Yes 04/01/10 04/01/11 J3110 Injection, teriparatide, 10 mcg Yes 01/01/11 J3285 Injection, treprostinil, 1 mg Yes 01/01/11 J3490 Drugs unclassified injection Yes 04/01/10 J3590 Unclassified biologics Yes 04/01/10 J7187 Humate‐P, inj Yes 12/01/08 J7189 Factor viia Yes 12/01/08 J7190 Factor viii Yes 12/01/08 J7191 Factor VIII (porcine) Yes 12/01/08 J7192 Factor viii recombinant Yes 12/01/08 J7193 Factor IX No ‐ APG Carve Outn‐recombinant Yes 12/01/08 J7194 Factor ix complex Yes 12/01/08 J7195 Factor IX recombinant Yes 12/01/08 J7197 Antithrombin iii injection Yes 12/01/08 J7198 Anti‐inhibitor Yes 12/01/08 J7199 Hemophilia clot factor No ‐ APG Carve Outc Yes 12/01/08 J7297 Levonorgestrel iu 52mg 3 yr Yes 07/01/16 J7298 Levonorgestrel iu 52mg 5 yr Yes 07/01/16 J7300 Intraut copper contraceptive Yes 12/01/08 J7301 Levonorgestrel iu 13.5 mg Yes 07/01/16 J7302 LevoNo ‐ APG Carve Outrgestrel iu contracept Yes 12/01/08 J7306 Levonorgestrel implant sys Yes 07/01/16 J7307 EtoNo ‐ APG Carve Outgestrel implant system Yes 12/01/08 J7320 Genvisc 850, inj, 1mg TBD 01/01/17 J7322 Hymovis injection 1 mg TBD 01/01/17 J8520 Capecitabine, oral, 150 mg Yes 01/01/11 J9001 Injection, doxorubicin hydrochloride, all lipid formulations Yes 01/01/11 J9019 Erwinaze injection Yes 07/01/14 J9027 Clofarabine injection Yes 12/01/08 J9033 Injection, bendamustine hcl, 1 mg Yes 01/01/11 J9035 Injection, bevacizumab, 10 mg Yes 01/01/11 J9055 Injection, cetuximab, 10 mg Yes 01/01/11 J9098 Injection, cytarabine liposome, 10 mg Yes 01/01/11 J9120 Injection, dactinomycin, 0.5 mg Yes 01/01/11 J9160 Injection, denileukin diftitox, 300 micrograms Yes 01/01/11 J9207 Injection, ixabepilone, 1 mg Yes 01/01/11 J9219 Leuprolide acetate implant, 65 mg Yes 01/01/11 J9225 Histrelin implant (vantas), 50 mg Yes 01/01/11 J9226 Supprelin LA implant Yes 10/01/10

Page 7 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List J9245 Injection, melphalan hydrochloride, 50 mg Yes 01/01/11 J9263 Injection, oxaliplatin, 0.5 mg Yes 01/01/11 J9264 Injection, paclitaxel protein‐bound particles, 1 mg Yes 01/01/11 J9266 Injection, pegaspargase, per single dose vial Yes 01/01/11 J9268 Injection, pentostatin, 10 mg Yes 01/01/11 J9303 Injection, panitumumab, 10 mg Yes 01/01/11 J9305 Injection, pemetrexed, 10 mg Yes 01/01/11 J9310 Injection, rituximab, 100 mg Yes 01/01/11 J9350 Injection, topotecan, 4 mg Yes 01/01/11 J9355 Injection, trastuzumab, 10 mg Yes 01/01/11 J9600 Injection, porfimer sodium, 75 mg Yes 01/01/11 Q0091 Obtaining screen pap smear No 01/01/12 Q2043 Provenge Yes 07/01/14 Q2049 Imported lipodox inj No 01/01/16 Q4074 Iloprost, inhalation solution, fda‐approved final product, n Yes 01/01/11 S0166 Inj olanzapine 2.5mg No 04/01/11 S0190 Mifepristone, oral, 200 mg Yes 12/01/08 S0191 Misoprostol, oral, 200 mcg Yes 12/01/08 S3800 Genetic testing als No 01/01/16 S3818 BRCA1 gene anal Yes 01/01/10 S3819 BRCA2 gene anal Yes 01/01/10 S3820 Comp BRCA1/BRCA2 Yes 01/01/10 S3822 Sing mutation brst/ovar Yes 01/01/10 S3823 3 mutation brst/ovar Yes 01/01/10 S3828 Comp MLH1 gene Yes 01/01/10 S3829 Comp MLH2 gene Yes 01/01/10 S3830 Gene test HNPCC comp Yes 01/01/10 S3831 Gene test HNPCC single Yes 01/01/10 S3833 Comp APC sequence Yes 01/01/10 S3834 Sing mutation APC Yes 01/01/10 S3835 Gene test cystic fibrosis Yes 01/01/10 S3840 DNA analysis RET‐oncogene Yes 01/01/10 S3841 Gene test retinoblastoma No 01/01/16 S3842 Gene test Hippel‐Lindau Yes 01/01/10 S3843 DNA analysis factor v Yes 01/01/10 S3844 DNA analysis deafness Yes 01/01/10 S3845 Gene test alpha‐thalassemia No 01/01/10 S3846 Gene test beta‐thalassemia Yes 01/01/10 S3847 Gene test Tay‐Sachs Yes 01/01/10 S3848 Gene test Gaucher Yes 01/01/10 S3849 Gene test Niemann‐Pick Yes 01/01/10 S3850 Gene test sickle cell Yes 01/01/10 S3851 Gene test canavan Yes 01/01/10 S3852 DNA analysis APOE alzheimer Yes 01/01/10 S3853 Gene test myo musclr dyst Yes 01/01/10 S3854 Gene profile panel breast No 01/01/16 S3861 Genetic test brugada Yes 01/01/16 S3865 Comp genet test hyp cardiomy Yes 01/01/16 S3866 Spec gene test hyp cardiomy Yes 01/01/16 S3870 Cgh test developmental delay No 01/01/16 S3890 Fecal dna analysis No 01/01/16 S4989 Contracept IUD Yes 12/01/08 S8940 Hippotherapy per session No 12/01/08 S9075 Smoking cessation treatment No 12/01/08 S9128 Speech therapy, in the home, No 12/01/08 S9129 Occupational therapy, in the No 12/01/08 S9131 PT in the home per diem No 12/01/08 S9453 Smoking cessation class No 12/01/08 S9480 Intensive outpatient psychia No 07/01/10 01/01/11 T1040 Comm bh clinic svc per diem TBD 01/01/17 T1041 Comm bh clinic svc per month TBD 01/01/17 V5014 Hearing aid repair/modifying Yes 04/01/12 V5362 Speech screening No 04/01/11

Page 8 of 9 Never Pay Px List Alternative Date subsequently Date added to Never Date Removed Px Code Procedure (Px) Description Payment added to Never Pay Pay List from Never Pay List Available* List V5364 Dysphagia screening No 04/01/11

*Procedure codes listed as carve outs should not be billed using APGs. Indication as a carve out does not guarantee alternative payment.

Yes = Procedure code is not payable in APGs but is available for billing on ordered ambulatory fee schedule.

No = Procedure code is not reimbursable by Medicaid. Service may be billable under an alternative procedure code.

TBD= At this time Medicaid Policy has not made a final determination regarding these procedures. Once a final determination has been made, they will be adjusted on this list or just added into the general APG logic.

Page 9 of 9 Never Pay Px List