INJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY …

1 CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESC9492 DURVALUMAB J0594 BUSULFAN J0640 LEUCOVORIN CALCIUM J0641 LEVOLEUCOVORIN CALCIUM J0881 DARBEPOETIN ALFA NON-ESRD USEJ0882 DARBEPOETIN ALFA ESRD ON DIALYSISJ0885 EPOETIN ALFA 1,000 NON-ESRD USEJ0894 DECITABINE J0897 DENOSUMAB J1050 MEDROXYPROGESTERONE ACETATE 1MG1, J1190 DEXRAZOXANE HCL J1260 DOLASETRON MESYLATE G-CSF J1447 TBO FILGRASTIM J1453 FOSAPREPITANT J1457 GALLIUM NITRATE HYDROCHLORIDE J1640 HEMIN J1930 LANREOTIDE J2355 OPRELVEKIN HCL J2430 PAMIDRONATE DISODIUM PER J2469 PALONOSETRON J2505 PEGFILGRASTIM 6MG15, J2562 PLERIXAFOR J2783 RASBURICASE J2820 SARGRAMOSTIM (GM-CSF) J3240 THYROTROPIN ALPHA J3315 TRIPTORELIN PAMOATE J3489 ZOLEDRONIC ACID INJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018 Page 1 of 5 CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESINJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018J9000 DOXORUBICIN HCL J9015 ALDESLEUKIN PER SINGLE USE J9017 ARSENIC TRIOXIDE J9019 ASPARAGINASE (ERWINAZE) 1, J9022 ATEZOLIZUMAB J9025 AZACITIDINE J9027 CLOFARABINE J9031 BCG LIVE INTRAVESICAL PER INSTILLATION BCG VACCINE TICE J9032 BELINOSTAT J9033 BENDAMUSTINE HCL 1MG (TREANDA) J9034 BENDAMUSTINE HCL 1MG (BENDEKA)

2 J9039 BLINATUMOMAB J9040 BLEOMYCIN SULFATE 15 J9041 BORTEZOMIB J9042 BRENTUXIMAB VEDOTIN J9043 CABAZITAXEL J9045 CARBOPLATIN J9047 CARFILZOMIB J9050 CARMUSTINE J9055 CETUXIMAB J9060 CISPLATIN POWDER OR SOLUTION PER J9065 CLADRIBINE PER J9070 CYCLOPHOSPHAMIDE J9098 CYTARABINE LIPOSOME J9100 CYTARABINE HCL J9120 DACTINOMYCIN J9150 DAUNORUBICIN Page 2 of 5 CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESINJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018J9151 DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION J9160 DENILEUKIN DIFTITOX 300 MCG21, J9175 ELLIOTT'S B SOLUTION J9178 EPIRUBICIN HCL J9179 ERIBULIN MESYLATE J9181 ETOPOSIDE J9185 FLUDARABINE PHOSPHATE J9190 FLUOROURACIL 500MG J9200 FLOXURIDINE J9201 GEMCITABINE HCL J9202 GOSERELIN ACETATE IMPLANT PER J9205 IRINOTECAN LIPOSOME J9206 IRINOTECAN J9207 IXABEPILONE PER J9211 IDARUBICIN HYDROCHLORIDE J9214 INTERFERON ALFA-2B RECOMBINANT 1 MILLION UNITS J9215 INTERFERON ALFA-N3 HUMAN LEUKOCYTE DERIVED 250, J9217 LEUPROLIDE ACETATE FOR DEPOT SUSPENSION J9225 HISTRELIN IMPLANT J9228 IPILIMUMAB TO 4 DOSES.

3 FOR REINDUCTION, WAIT MINIMUM OF 12 WKS AND BILL J9999 FOR UP TO 4 ADD'L DOSESPage 3 of 5 CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESINJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018J9230 MECHLORETHAMINE HCL (NITROGEN MUSTARD) HYDROCHLORIDE SODIUM PER SODIUM PER MEPESUCCINATE PROTEIN-BOUND PARTICLES PER SINGLE DOSE VIAL PER HCL PER J9299 NIVOLUMAB 4 of 5 CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESINJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018J9354 ADO-TRASTUZUMAB EMTANSINE INTRAVESICAL 200MG41, SULFATE SULFATE SULFATE LIPOSOME TARTRATE PER AFLIBERCEPT MINIMUM 50 MILLION AUTOLOGOUS C54+CELLS ACTIVATED W/PAP-GM-CSF PER INFUSION140, LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURESQ2049 DOXORUBICIN HCL LIPOSOMAL IMPORTED LIPODOX HCL LIPOSOMAL NOS (G-CSF) BIOSIMILAR 5 of 5