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Drug HCPCS/ CPT Codes Requiring NDC (Effective Date Based

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Drug HCPCS/ CPT Codes Requiring NDC (Effective Date Based July 2021 Drug HCPCS/ CPT Codes Requiring NDC (Effective Date Based on Date Received) Inst (837I) NDC-Prof (837P) NDC- HCPCS/ HCPCS/CPT Description Required Required CPT Effective Date Effective Date 90281 Immune globulin (IG), human, for intramuscular use 10/01/2017 10/01/2017 90283 Immune globulin (IGIV), human, for intravenous use 10/01/2017 10/01/2017 90284 Immune globulin (SCIG), human, for use in subcutaneous infusions, 100 mg, each 10/01/2017 10/01/2017 90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each 10/01/2017 10/01/2017 90399*** Unlisted immune globulin 11/14/2016 10/01/2009 90749*** Unlisted vaccine/toxoid 11/14/2016 10/01/2009 A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries 10/01/2017 10/01/2017 A9590 Iodine i-131, iobenguane, 1 millicurie 01/01/2020 01/01/2020 A9606 Radium Ra 223 dichloride therapeutic 10/01/2017 10/01/2017 A9699*** Radiopharmaceutical, therapeutic, not otherwise classified 11/14/2016 10/01/2009 C9047 Injection, caplacizumab-yhdp, 1 mg 07/01/2019 not billable① C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg 10/01/2020 not billable① C9075** Injection, casimersen, 10 mg 07/01/2021 not billable① Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, C9076** 07/01/2021 not billable① including leukapheresis and dose preparation procedures, per therapeutic dose C9077** Injection, cabotegravir and rilpivirine, 2mg/3mg 07/01/2021 not billable① C9078** Injection, trilaciclib, 1 mg 07/01/2021 not billable① C9079** Injection, evinacumab-dgnb, 5 mg 07/01/2021 not billable① C9080** Injection, melphalan flufenamide hydrochloride, 1 mg 07/01/2021 not billable① C9122 Mometasone furoate sinus implant, 10 micrograms (sinuva) 07/01/2020 not billable① C9257 Injection, bevacizumab, 0.25 mg 10/01/2017 not billable① C9399*** Unclassified drugs or biologicals 11/14/2016 not billable① C9462 Injection, delafloxacin, 1 mg 04/01/2018 not billable① C9488 Injection, conivaptan hydrochloride, 1 mg (Vaprisol) (drug aligns with unclassified HCPCS, J3490) 04/01/2017 not billable① D9630*** Other drugs and/or medicaments, by report 11/14/2016 10/01/2009 J0120 Injection, tetracycline, up to 250 mg 10/01/2017 10/01/2017 J0129 Injection, abatacept, 10 mg 10/01/2017 10/01/2017 Drug HCPCS/ CPT Codes Requiring NDC (Effective Date Based on Date Received) Inst (837I) NDC-Prof (837P) NDC- HCPCS/ HCPCS/CPT Description Required Required CPT Effective Date Effective Date J0135 Injection, adalimumab, 20 mg 10/01/2017 10/01/2017 J0178 Injection, aflibercept, 1 mg 10/01/2017 10/01/2017 J0179 Injection, brolucizumab-dbll, 1 mg 01/01/2020 01/01/2020 J0180 Injection, agalsidase beta, 1 mg 10/01/2017 10/01/2017 J0185 Injection, Aprepitant, 1 mg 01/01/2019 01/01/2019 J0190 Injection, biperiden lactate, per 5 mg 10/01/2017 10/01/2017 J0200 Injection, alatrofloxacin mesylate, 100 mg 10/01/2017 10/01/2017 J0202 Injection, alemtuzumab, 1 mg 10/01/2017 10/01/2017 J0205 Injection, alglucerase, per 10 units 10/01/2017 10/01/2017 J0207 Injection, amifostine, 500 mg not required 10/01/2017 J0215 Injection, alefacept, 0.5 mg 10/01/2017 10/01/2017 J0220 Injection, alglucosidase alfa, 10 mg, not otherwise specified 10/01/2017 10/01/2017 J0221 Injection alglucosidase alfa, (Lumizyme), 10 mg 10/01/2017 10/01/2017 J0222 Injection, Patisiran, 0.1 mg 10/01/2019 10/01/2019 J0223 Injection, givosiran, 0.5 mg 07/01/2020 07/01/2020 J0224** Injection, lumasiran, 0.5 mg 07/01/2021 07/01/2021 J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg 10/01/2017 10/01/2017 J0257 Injection, alpha 1-proteinase inhibitor (human), (Glassia), 10 mg 10/01/2017 10/01/2017 J0288 Injection, amphotericin B cholesteryl sulfate complex, 10 mg 10/01/2017 10/01/2017 J0330 Injection, succinylcholine chloride, up to 20 mg not required 10/01/2017 J0350 Injection, anistreplase, per 30 units 10/01/2017 10/01/2017 J0365 Injection, aprotinin, 10,000 KIU 10/01/2017 10/01/2017 J0380 Injection, metaraminol bitartrate, per 10 mg 10/01/2017 10/01/2017 J0390 Injection, chloroquine hcl, up to 250 mg 10/01/2017 10/01/2017 J0395 Injection, arbutamine hcl, 1 mg 10/01/2017 10/01/2017 J0400 Injection, aripiprazole, intramuscular, 0.25 mg 10/01/2017 10/01/2017 J0401 Injection, aripiprazole, extended release, 1 mg 10/01/2017 10/01/2017 J0470 Injection, dimercaprol, per 100 mg 10/01/2017 10/01/2017 J0475 Injection, baclofen, 10 mg not required 07/01/2015 J0476 Injection, baclofen, 50 mcg for intrathecal trial not required 07/01/2015 J0490 Injection, belimumab, 10 mg 10/01/2017 10/01/2017 J0517 Injection, Benralizumab, 1 mg 01/01/2019 01/01/2019 Drug HCPCS/ CPT Codes Requiring NDC (Effective Date Based on Date Received) Inst (837I) NDC-Prof (837P) NDC- HCPCS/ HCPCS/CPT Description Required Required CPT Effective Date Effective Date J0520 Injection, bethanechol chloride, myotonachol or urecholine, up to 5 mg 10/01/2017 10/01/2017 J0565 Injection, bezlotoxumab, 10 mg 01/01/2018 01/01/2018 J0567 Injection, Cerliponase alfa, 1 mg 01/01/2019 01/01/2019 J0570 Buprenorphine implant, 74.2 mg 10/01/2017 10/01/2017 J0571 Buprenorphine/naloxone, oral, less than or equal to 3 mg buprenorphine not required 10/01/2017 J0572 Buprenorphine/naloxone, oral, less than or equal to 3 mg buprenorphine not required 10/01/2017 J0573 Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 3.1 to 6 mg not required 10/01/2017 J0574 Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg buprenorphine not required 10/01/2017 J0575 Buprenorphine/naloxone, oral, greater than 10 mg buprenorphine not required 10/01/2017 J0584 Injection, Burosumab-twza 1 mg 01/01/2019 01/01/2019 J0585 Injection, onabotulinumtoxinA, 1 unit 10/01/2017 10/01/2017 J0586 Injection, abobotulinumtoxinA, 5 units 10/01/2017 10/01/2017 J0587 Injection, rimabotulinumtoxinB, 100 units 10/01/2017 10/01/2017 J0588 Injection, incobotulinumtoxinA, 1 unit 10/01/2017 10/01/2017 J0591 Injection, deoxycholic acid, 1 mg 07/01/2020 07/01/2020 J0592 Injection, buprenorphine hcl, 0.1 mg 10/01/2017 10/01/2017 J0593 Injection, lanadelumab-flyo, 1 mg 10/01/2019 10/01/2019 J0594 Injection,busulfan, 1 mg not required 10/01/2017 J0595 Injection, butorphanol tartrate, 1 mg 10/01/2017 10/01/2017 J0596 Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 units 10/01/2017 10/01/2017 J0597 C1 esterase, Berinert 10/01/2017 10/01/2017 J0598 C1 esterase, Cinryze 10/01/2017 10/01/2017 J0599 Injection, C-1 esterase inhibitor (human), (Haegarda), 10 units 01/01/2019 01/01/2019 J0600 Injection, edetate calcium disodium, up to 1000 mg 10/01/2017 10/01/2017 J0620 Injection, calcium glycerophosphate and calcium lactate, per 10 ml 10/01/2017 10/01/2017 J0638 Canakinumab Injection 10/01/2017 10/01/2017 J0640 Injection, leucovorin calcium, per 50 mg 10/01/2017 10/01/2017 J0641 Injection, levoleucovorin calcium, 0.5 mg 10/01/2017 10/01/2017 J0670 Injection, mepivacaine hcl, per 10 ml not required 10/01/2017 J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg not required 10/01/2017 J0717 Injection, certolizumab pegol, 1 mg 10/01/2017 10/01/2017 J0725 Injection, chorionic gonadotropin, per 1000 usp units 10/01/2017 10/01/2017 Drug HCPCS/ CPT Codes Requiring NDC (Effective Date Based on Date Received) Inst (837I) NDC-Prof (837P) NDC- HCPCS/ HCPCS/CPT Description Required Required CPT Effective Date Effective Date J0735 Injection, clonidine hcl, 1 mg not required 07/01/2015 J0745 Injection, codeine phosphate, per 30 mg not required 07/01/2015 J0775 Collagenase, clostridium histolyticum injection 10/01/2017 10/01/2017 J0780 Injection, prochlorperazine, up to 10 mg not required 10/01/2017 J0791 Injection, crizanlizumab-tmca, 5 mg 07/01/2020 07/01/2020 J0800 Injection, corticotropin, up to 40 units 10/01/2017 10/01/2017 J0834 Injection, cosyntropin (cortrosyn), 0.25mg not required 10/01/2017 J0850 Injection, cytomegalovirus immune globulin intravenous (human), per vial not required 10/01/2017 J0881 Injection, darbepoetin alfa, 1 mcg (non-esrd use) 10/01/2017 10/01/2017 J0883 Injection, argatroban, 1 mg (for non-esrd use) 10/01/2017 10/01/2017 J0885 Injection, eponetin alfa, (for non-esrd use), 1000 units 10/01/2017 10/01/2017 J0888 Epoetin beta non-esrd 10/01/2017 10/01/2017 J0894 Injection, decitabine, 1 mg 10/01/2017 10/01/2017 J0895 Injection, deferoxamine mesylate, 500 mg not required 10/01/2017 J0896 Injection, luspatercept-aamt, 0.25 mg 07/01/2020 07/01/2020 J0897 Injection, denosumab, 1 mg 10/01/2017 10/01/2017 J0945 Injection, brompheniramine maleate, per 10 mg 10/01/2017 10/01/2017 J1020 Injection, methylprednisolone acetate, 20 mg not required 10/01/2017 J1030 Injection, methylprednisolone acetate, 40 mg not required 10/01/2017 J1040 Injection, methylprednisolone acetate, 80 mg not required 10/01/2017 J1094 Injection, dexamethasone acetate, 1 mg 10/01/2017 10/01/2017 J1100 Injection, dexamethasone sodium phosphate, 1 mg not required 10/01/2017 J1110 Injection, dihydroergotamine mesylate, per 1 mg not required 10/01/2017 J1170 Injection, hydromorphone, up to 4 mg not required 07/01/2015 J1180 Injection, dyphylline, up to 500 mg 10/01/2017 10/01/2017 J1230 Injection, methadone hcl, up to 10 mg not required 07/01/2015 J1260 Injection, dolasetron mesylate, 10 mg 10/01/2017 10/01/2017 J1290 Ecallantide injection 10/01/2017 10/01/2017 J1300 Injection, eculizumab, 10 mg 10/01/2017 10/01/2017 J1301 Injection, Edaravone, 1 mg 01/01/2019 01/01/2019
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