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TBSP10616-E (2/20)

Department of Health Care Services Healthcare Common Procedure Coding System List

Each HCPCS code in this list must be accompanied by a valid NDC in the LIN03 segment of the HIPAA 837 transaction when submitted for encounters/claims for Blue Shield of California Promise Health Plan members.

Code Description A4802 PROTAMINE SULFATE PER 50 MG A9513 LUTETIUM LU 177 DOTATAT THER A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAP A9590 IODINE I-131 IOBENGUANE 1MCI A9606 RADIUM RA223 DICHLORIDE THER C9014 INJECTION, CERLIPONASE ALFA C9015 C-1 ESTERASE, HAEGARDA C9016 INJ, TRIPTORELIN EXT REL C9021 INJECTION, OBINUTUZUMAB 10 MG C9022 ELOSULFASE ALFA INJECTION, 1MG C9023 INJ TESTOSTERONE UNDECANOATE 1 MG C9024 INJ, DAUNORUBICIN-CYTARABINE C9025 INJ, RAMUCIRUMAB, 5 MG C9026 INJECTION, VEDOLIZUMAB, 1 MG C9027 INJECTION, PEMBROLIZUMAB C9028 INJ. INOTUZUMAB OZOGAMICIN C9029 INJECTION, GUSELKUMAB C9030 COPANLISIB C9031 LUTETIUM LU 177 DOTATE TX C9032 VORETIGENE NEPARVOVEC-RZYL C9033 INJ, AKYNZEO C9034 INJECTION, DEXAMETHASONE 9%, C9036 INJECTION, PATISIRAN C9038 INJ MOGAMULIZUMAB-KPKC C9039 INJECTION, PLAZOMICIN C9040 INJECTION, FREMANEZUMAB-VFRM C9041 INJ, COAGULATION FACTOR XA

Code Description C9042 INJ., BELRAPZO 1 MG C9043 INJECTION, LEVOLEUCOVORIN C9044 INJECTION, CEMIPLIMAB-RWLC C9045 MOXETUMOMAB PASUDOTOX-TDFK C9046 COCAINE HCL NASAL SOLUTION C9047 INJECTION, CAPLACIZUMAB-YHDP C9048 DEXAMETHASONE OPHTH INSERT C9049 INJECTION, TAGRAXOFUSP-ERZS C9050 INJECTION, EMAPALUMAB-LZSG C9051 INJECTION, OMADACYCLINE C9052 INJECTION, RAVULIZUMAB-CWV C9054 INJECTION, LEFAMULIN C9055 INJ, BREXANOLONE C9113 INJECTION, PANTOPRAZOLE SODIUM, PER VIAL C9121 INJECTION, ARGATROBAN, PER 5 MG C9130 IVIG BIVIGAM 500 MG C9131 ADO-TRASTUZUMAB EMTANSINE 1 MG C9132 KCENTRA, PER I.U. C9133 FACTOR IX RECOMBINANT C9134 FACTOR XIII, ANTIHEMOPHILLIC FACTOR, REC C9137 ADYNOVATE FACTOR VIII RECOM C9138 NUWIQ FACTOR VIII RECOMB C9140 AFSTYLA FACTOR VIII RECOMB C9141 INJ., VIII, PEGYLATED-AUCL, 1 IU C9237 INJ, LANREOTIDE ACETATE C9238 INJ, LEVETIRACETAM C9239 INJ, TEMSIROLIMUS


TBSP10616-E (2/20)

Code Description C9240 INJECTION, IXABEPILONE C9244 INJECTION, REGADENOSON C9245 INJECTION, ROMIPLOSTIM C9248 INJ, CLEVIDIPINE BUTYRATE C9249 CERTOLIZUMAB PEGOL 1MG C9252 PLERIXAFOR 1MG C9254 INJECTION, LACOSAMIDE C9255 PALIPERIDONE PALMITATE INJ C9256 DEXAMETHASONE INTRAVITREAL C9257 BEVACIZUMAB INJECTION C9259 PRALTREXATE 1 MG C9260 OFATUMUMAB 10 MG C9264 TOCILIZUMAB 1 MG C9265 ROMIDPEPSIN 1 MG C9270 GAMMAPLEX IVIG C9272 DENOSUMAB, 1 MG C9274 CROTALIDAE POLY IMMUNE FAB C9275 HEXAMINOLEVULINATE HCL C9276 CABAZITAXEL INJECTION C9277 LUMIZYME, 1 MG C9278 INCOBOTULINUMTOXIN A C9279 INJECTION, IBUPROFEN C9280 ERIBULIN MESYLATE 1 MG C9285 PATCH, LIDOCAINE/TETRACAINE C9286 INJECTION, BELATACEPT C9287 INJ, BRENTUXIMAB VEDOTIN C9288 CENTRUROIDES (SCORPION) IMMUNE F(AB)2 C9289 ASPARAGINASE ERWINIA CHRYSANTHEMI C9290 BUPIVACAINE LIPOSOME 1 MG C9292 INJECTION, PERTUZUMAB, 10MG C9293 INJECTION, GLUCARPIDASE, 10 UNITS C9294 INJ, TALIGLUCERASE ALFA

Code Description C9295 INJECTION, CARFILZOMIB C9296 INJECTION, ZIV-AFLIBERCEPT C9297 OMACETAXINE MEPESUCCINATE C9298 OCRIPLASMIN, 0.125 MG C9399 UNCLASSIFIED DRUGS OR BIOLOG C9441 FERRIC CARBOXYMALTOSE 1MG INJECTION C9442 INJECTION, BELINOSTAT C9443 INJECTION, DALBAVANCIN C9444 INJECTION, ORITAVANCIN C9445 INJ. C-1 ESTERASE, RUCONEST, 10 UNITS C9446 INJ, TEDIZOLID PHOSPHATE C9447 INJ, PHENYLEPHRINE KETOROLAC C9448 ORAL NETUPITANT PALONOSETRON C9449 BLINATUMOMAB, 1 MCG C9450 FLUOCINOLONE ACETONIDE IMPLT C9451 INJ. PERAMIVIR, 1 MG C9452 INJ. CEFTOLOZANE/TAZOBACTAM C9453 INJECTION, NIVOLUMAB, 1 MG C9454 INJ, PASIREOTIDE LONG ACTING C9455 INJECTION, SILTUXIMAB C9456 INJECTION, ISAVUCONAZONIUM SULFATE, 1 MG C9460 INJECTION, CANGRELOR C9462 INJECTION, DELAFLOXACIN C9463 INJECTION, APREPITANT C9464 INJECTION, ROLAPITANT C9466 INJECTION, BENRALIZUMAB C9467 INJECTION, RITUXIMAB HYALURONIDASE C9469 INJECTION, TRIMCINOLONE C9470 APIRIPRAZOLE LAUROXIL IM C9472 INJ, TALIMOGENE LAHERPARPVEC C9473 INJ, MEPOLIZUMAB LAHERPAREPVEC C9474 INJ, IRINOTECAN LIPOSOME


TBSP10616-E (2/20)

Code Description C9475 INJECTION, NECITUMUMAB C9481 INJECTION, RESLIZUMAB C9482 SOTALOL HYDROCHLORIDE IV C9483 INJECTION, ATEZOLIZUMAB 10MG C9484 INJECTION ETEPLIRSEN 10 MG C9485 INJECTION OLARATUMAB 10 MG C9486 INJ. GRANISETRON EXTENDED RELEASE 0.1 MG C9487 INJECTION USTEKINUMAB IV INJ. 1 MG C9488 INJECTION CONIVAPTAN HCL, 1 MG C9489 INJECTION, NUSINERSEN C9490 INJECTION, BEZIOTOXUMAB C9491 INJECTION, AVELUMAB, 10 MG C9492 INJECTION, DURVALUMAB C9493 INJECTION, EDARAVONE C9494 INJECTION, OCRELIZUMAB, 1MG C9497 LOXAPINE, INHALATION POWDER G9033 AMANTADINE HCL ORAL BRAND J0121 INJ., OMADACYCLINE, 1 MG J0122 INJ., ERAVACYCLINE, 1 MG J0128 ABARELIX INJECTION J0129 ABATACEPT INJECTION J0130 ABCIXIMAB INJECTION J0131 ACETAMINOPHEN INJECTION J0132 ACETYLCYSTEINE INJECTION J0133 ACYCLOVIR INJECTION J0135 ADALIMUMAB INJECTION J0150 INJECTION ADENOSINE 6 MG J0151 ADENOSINE INJECTION J0152 ADENOSINE INJECTION J0153 ADENOSINE INJ 1MG J0170 INJECTION, ADRENALIN, EPINEPHRINE, J0171 ADRENALIN EPINEPHRINE INJECT

Code Description J0178 AFLIBERCEPT INJECTION J0179 INJ, BROLUCIZUMAB-DBLL, 1 MG J0180 AGALSIDASE BETA 1 MG J0185 INJ., APREPITANT, 1 MG J0190 INJECTION, BIPERIDEN, 2 MG J0200 ALATROFLOXACIN MESYLATE J0202 INJECTION, ALEMTUZUMAB J0205 INJECTION, ALGLUCERASE, PER 10 UNITS J0207 AMIFOSTINE J0210 INJECTION, METHYLDOPATE HCL, UP TO J0215 ALEFACEPT J0220 ALGLUCOSIDASE ALFA INJECTION J0221 LUMIZYME INJECTION J0222 INJ., PATISIRAN, 0.1 MG J0256 ALPHA 1 PROTEINASE INHIBITOR J0257 GLASSIA INJECTION J0270 ALPROSTADIL FOR INJECTION J0275 ALPROSTADIL URETHRAL SUPPOS J0278 AMIKACIN SULFATE INJECTION J0280 INJECTION, AMINOPHYLLIN, UP TO 250 J0282 AMIODARONE HCL J0285 AMPHOTERICIN B J0287 AMPHOTERICIN B LIPID COMPLEX J0288 AMPHO B CHOLESTERYL SULFATE J0289 AMPHOTERICIN B LIPOSOME INJ J0290 AMPICILLIN 500 MG INJ J0291 INJ., PLAZOMICIN, 5 MG J0295 AMPICILLIN SULBACTAM 1.5 GM J0300 INJECTION, AMOBARBITAL, UP TO 125 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE J0348 ANIDULAFUNGIN INJECTION J0350 INJECTION ANISTEPLASE PER 30 UNITS


TBSP10616-E (2/20)

Code Description J0360 INJECTION, HYDRALAZINE HCL, UP TO J0364 APOMORPHINE HYDROCHLORIDE J0365 APROTONIN, 10,000 KIU J0380 INJECTION, METARAMINOL UP TO 10 MG J0390 INJECTION, CHLOROQUINE HCL, UP TO J0395 ARBUTAMINE HCL INJECTION J0400 *08ARIPIPRAZOLE INJECTION J0401 INJ ARIPIPRAZOLE EXT REL 1MG J0456 AZITHROMYCIN J0460 INJECTION, ATROPINE SULFATE, UP TO J0461 ATROPINE SULFATE INJECTION J0470 INJECTION, DIMERCAPROL, UP TO 100 M J0475 INJECTION, BACLOFEN, 10 MG J0476 BACLOFEN INTRATHECAL TRIAL J0480 BASILIXIMAB J0485 BELATACEPT INJECTION J0490 BELIMUMAB INJECTION J0500 INJECTION, DICYCLOMINE, UP TO 20 M J0515 INJECTION, BENZTROPINE J0517 INJ., BENRALIZUMAB, 1 MG J0520 INJECTION, BETHANECHOL CHLORIDE, M J0530 INJECTION, PENICILLIN G BENZATHINE J0540 INJECTION, PENICILLIN G BENZATHINE J0550 INJECTION, PENICILLIN G BENZATHINE J0558 PENG BENZATHINE/PROCAINE INJ J0559 PENG BENZATHINE/PROCAINE INJ J0560 INJECTION, PENICILLIN G BENZATHINE J0561 PENICILLIN G BENZATHINE INJ J0565 INJ, BEZLOTOXUMAB, 10 MG J0567 INJ., CERLIPONASE ALFA 1 MG J0570 INJECTION, PENICILLIN G BENZATHINE J0571 BUPRENORPHINE ORAL 1MG

Code Description J0572 BUPRENORPHIN/NALOX UP TO 3MG J0573 BUPRENORPH/NALOX 3.1 TO 6MG J0574 BUPRENORPH/NALOX 6.1 TO 10MG J0575 BUPRENORPH/NALOX OVER 10MG J0580 INJECTION, PENICILLIN G BENZATHINE J0583 BIVALIRUDIN J0585 BOTULINUM TOXIN TYPE A, PER 1 UNIT J0586 ABOBOTULINUMTOXINA J0587 BOTULINUM TOXIN TYPE B, PER 100 UNITS J0588 INCOBOTULINUMTOXIN A J0592 BUPRENORPHINE HYDROCHLORIDE J0593 INJ., LANADELUMAB-FLYO, 1 MG J0594 BUSULFAN INJECTION J0595 BUTORPHANOL TARTRATE 1 MG J0596 INJECTION, RUCONEST J0597 C-1 ESTERASE, BERINERT J0598 C-1 ESTERASE, CINRYZE J0600 INJECTION, EDETATE CALCIUM DISODIU J0604 CINACALCET, ESRD ON DIALYSIS J0606 INJECTION, ETELCALCETIDE, 0.1 MG J0610 INJECTION, CALCIUM GLUCONATE, UP T J0620 CALCIUM GLYCEROPHOSPHAT&CALCIUM LACTATE J0630 INJECTION, CALCITONIN SALMON, UP T J0636 INJ CALCITRIOL PER 0.1 MCG J0637 CASPOFUNGIN ACETATE J0638 CANAKINUMAB INJECTION J0640 INJECTION, LEUCOVORIN CALCIUM, PER J0641 INJ., LEVOLEUCOVORIN, 0.5 MG J0642 INJECTION, KHAPZORY, 0.5 MG J0670 INJECTION, MEPIVACAINE J0690 CEFAZOLIN SODIUM INJECTION J0692 CEFEPIME HCL FOR INJECTION


TBSP10616-E (2/20)

Code Description J0694 INJECTION, CEFOXITIN SODIUM, 1 GM J0695 INJ CEFTOLOZANE TAZOBACTAM J0696 INJECTION, CEFTRIAXONE SODIUM, PER J0697 INJECTION, STERILE CEFUROXIME SODI J0698 CEFOTAXIME SODIUM, PER GM J0702 BETAMETHASONE ACET&SOD PHOSP J0704 INJECTION BETAMETHASONE SODIUM PHOSPHATE J0706 CAFFEINE CITRATE INJECTION J0710 INJECTION, CEPHAPIRIN SODIUM, UP T J0712 CEFTAROLINE FOSAMIL INJ J0713 INJECTION, CEFTAZIDIME, PER 500 MG J0714 CEFTAZIDIME AND AVIBACTAM J0715 INJECTION CEFTIZOXIME SODIUM PER 500MG J0716 CENTRUROIDES IMMUNE F(AB) J0717 CERTOLIZUMAB PEGOL INJ 1MG J0718 CERTOLIZUMAB PEGOL INJ J0720 INJECTION, CHLORAMPHENICOL SODIUM J0725 CHORIONIC GONADOTROPIN PER 1000 USP UNIT J0735 CLONIDINE HYDROCHLORIDE, 1 MG J0740 CIDOFOVIR INJECTION J0743 INJECT, CILASTATIN SODIUM; IMIPENEM 250MG J0744 CIPROFLOXACIN IV J0745 INJECTION CODEINE PHOSPHATE PER 30 MG J0760 INJECTION, COLCHICINE, UP TO 2MG J0770 INJECTION, COLISTIMETHATE SODIUM, J0775 COLLAGENASE, CLOST HIST INJ J0780 INJECTION, PROCHLORPERAZINE, UP TO J0795 CORTICORELIN OVINE TRIFLUTATE, 1 MCG J0800 CORTICOTROPIN INJECTION J0833 COSYNTROPIN INJECTION NOS J0834 COSYNTROPIN CORTROSYN INJ J0835 INJECTION COSYNTROPIN PER 0.25MG

Code Description J0840 *12CROTALIDAE POLY IMMUNE FAB J0841 INJ CROTALIDAE IM F(AB')2 EQ J0850 INJECTION CYTOMEGALOVIRUS IMMUNE GLOBULI J0875 INJECTION, DALBAVANCIN J0878 DAPTOMYCIN INJECTION J0881 DARBEPOETIN ALFA, NON-ESRD J0882 DARBEPOETIN ALFA, ESRD USE J0883 ARGATROBAN NONESRD USE 1MG J0884 ARGATROBAN ESRD DIALYSIS 1MG J0885 EPOETIN ALFA, NON-ESRD J0886 EPOETIN ALFA 1000 UNITS ESRD J0887 EPOETIN BETA ESRD USE J0888 EPOETIN BETA NON ESRD J0890 PEGINESATIDE INJECTION J0894 DECITABINE INJECTION J0895 DEFEROXAMINE MESYLATE 500 MG J0897 DENOSUMAB INJECTION J0900 INJECTION, TESTOSTERONE ENANTHATE J0945 INJECTION, BROMPHENIRAMINE MALEATE J0970 INJECTION, ESTRADIOL VALERATE, UP J1000 INJECTION, DEPOESTRADIOL CYPIONAT J1020 INJECTION, METHYLPREDNISOLONE ACET J1030 INJECTION, METHYLPREDNISOLONE ACET J1040 INJECTION, METHYLPREDNISOLONE ACET J1050 MEDROXYPROGESTERONE INJ J1051 MEDROXYPROGESTERONE INJ J1055 INJEC MEDROXPROGESTRONE ACETATE CONTRACE J1056 MA/EC CONTRACEPTIVEINJECTION J1060 INJECTION, TESTOSTERONE CYPIONATE J1070 INJECTION, TESTOSTERONE CYPIONATE, J1071 INJ TESTOSTERONE CYPIONATE J1080 INJECTION, TESTOSTERONE CYPIONATE,


TBSP10616-E (2/20)

Code Description J1094 INJ DEXAMETHASONE ACETATE J1095 INJECTION, DEXAMETHASONE 9% J1096 DEXAMETHA OPTH INSERT 0.1 MG J1097 PHENYLEP KETOROLAC OPTH SOLN J1100 DEXAMETHASONE SODIUM PHOS J1110 INJECTION, DEHYDROERGOTAMINE, UP T J1120 INJECTION, ACETAZOLAMIDE SODIUM, U J1130 INJ DICLOFENAC SODIUM 0.5MG J1160 INJECTION, DIGOXIN, UP TO 0.5 MG J1162 DIGOXIN IMMUNE FAB (OVINE) J1165 INJECTION, PHENYTOIN SODIUM J1170 INJECTION, HYDROMORPHONE, UP TO 4 J1180 INJECTION, DYPHYLLINE, UP TO 500 M J1190 DEXRAZOXANE HCL INJECTION J1200 INJECTION, DIPHENHYDRAMINE HCL, UP J1205 INJECTION, CHLOROTHIAZIDE SODIUM J1212 INJECT DMSO DIMETHYL SULFOXID 50%,50 ML J1230 INJECTION, METHADONE HCL, UP TO 10 J1240 INJECTION, DIMENHYDRINATE, UP TO 5 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG J1250 DOUBUTAMINE HYDROCHLORIDE, 250 MG J1260 DOLASETRON MESYLATE J1265 DOPAMINE INJECTION J1267 DORIPENEM INJECTION J1270 INJECTION, DOXERCALCIFEROL J1290 ECALLANTIDE INJECTION J1300 ECULIZUMAB INJECTION J1301 INJECTION, EDARAVONE, 1 MG J1303 INJ., RAVULIZUMAB-CWVZ 10 MG J1320 INJECTION, AMITRIPTYLINE HCL, UP T J1322 ELOSULFASE ALFA, INJECTION J1324 ENFUVIRTIDE INJECTION

Code Description J1325 EPOPROSTENOL INJECTION J1327 EPTIFIBATIDE INJECTION J1330 INJECTION, ERGONOVINE MALEATE, UP J1335 ERTAPENEM INJECTION J1364 INJECTION ERYTHROMYCIN LACTOBIONATE PER J1380 INJECTION, ESTRADIOL VALERATE, UP J1390 INJECTION, ESTRADIOL VALERATE, UP J1410 INJECTION, ESTROGEN CONJUGATED, PER 25 MG J1428 INJ, ETEPLIRSEN, 10 MG J1430 ETHANOLAMINE OLEATE 100 MG J1435 INJECTION, ESTRONE PER 1 MG J1436 INJECTION, ETIDRONATE DISODIUM, PE J1438 ETANERCEPT INJECTION J1439 INJ FERRIC CARBOXYMALTOS 1MG J1440 INJECTION, FILGRASTIM (G-CSF), 300 MCG J1441 INJECTION, FILGRASTIM, (G-CSF), 480 MCG J1442 INJ, FILGRASTIM G-CSF 1MCG J1443 INJ FERRIC PYROPHOSPHATE CIT J1444 FE PYRO CIT POW 0.1 MG IRON J1446 INJ, TBO-FILGRASTIM, 5 MCG J1447 INJ TBO FILGRASTIM 1 MICROG J1450 FLUCONAZOLE J1451 FOMEPIZOLE, 15 MG J1452 INTRAOCULAR FOMIVIRSEN NA J1453 FOSAPREPITANT INJECTION J1454 INJ FOSNETUPITANT, PALONOSET J1455 INJECTION, FOSCARNET SODIUM, PER 1000MG J1457 GALLIUM NITRATE INJECTION J1458 GALSULFASE 1 MG J1459 INJ IVIG PRIVIGEN 500 MG J1460 INJECTION, GAMMA GLOBULIN, INTRAMU J1470 INJECTION, GAMMA GLOBULIN, INTRAMU


TBSP10616-E (2/20)

Code Description J1480 INJECTION, GAMMA GLOBULIN, INTRAMU J1490 INJECTION, GAMMA GLOBULIN, INTRAMU J1500 INJECTION, GAMMA GLOBULIN, INTRAMU J1510 INJECTION, GAMMA GLOBULIN, INTRAMU J1520 INJECTION, GAMMA GLOBULIN, INTRAMU J1530 INJECTION, GAMMA GLOBULIN, INTRAMU J1540 INJECTION, GAMMA GLOBULIN, INTRAMU J1550 INJECTION, GAMMA GLOBULIN, INTRAMU J1555 INJ CUVITRU, 100 MG J1556 INJ, IMM GLOB BIVIGAM, 500MG J1557 GAMMAPLEX INJECTION J1559 HIZENTRA INJECTION J1560 INJECTION, GAMMA GLOBULIN, INTRAMU J1561 *08GAMUNEX INJECTION J1562 VIVAGLOBIN, INJ J1565 RSV-IVIG J1566 IMMUNE GLOBULIN, POWDER J1568 OCTAGAM INJECTION J1569 GAMMAGARD LIQUID INJECTION J1570 INJECTION, GANCICLOVIR SODIUM,500 MG J1571 HEPAGAM B IM INJECTION J1572 FLEBOGAMMA INJECTION J1573 HEPAGAM B INTRAVENOUS, INJ J1575 HYQVIA 100MG IMMUNEGLOBULIN J1580 INJECTION, GARAMYCIN, GENTAMICIN, J1590 GATIFLOXACIN INJECTION J1595 INJECTION GLATIRAMER ACETATE J1599 IVIG NON-LYOPHILIZED, NOS J1600 INJECTION, GOLD SODIUM THIOMALEATE J1602 GOLIMUMAB FOR IV USE 1MG J1610 INJECTION GLUCAGON HYDROCHLORIDE PER 1MG J1620 INJECTION GONADORELIN HYDROCHLORIDE PER

Code Description J1626 GRANISETRON HCL INJECTION J1627 INJ, GRANISETRON, XR, 0.1 MG J1628 INJ., GUSELKUMAB, 1 MG J1630 INJECTION, HALOPERIDOL, UP TO 5 MG J1631 HALOPERIDOL DECANOATE, 50 MG J1640 *04 *06 HEMIN, 1 MG J1644 INJECTION HEPARIN SODIUM PER 1000 UNITS J1645 DALTEPARIN SODIUM J1650 INJ ENOXAPARIN SODIUM J1652 FONDAPARINUX SODIUM J1655 TINZAPARIN SODIUM INJECTION J1670 INJECTION, TETANUS IMMUNE GLOBULIN J1675 HISTRELIN ACETATE J1680 HUMAN FIBRINOGEN CONC INJ J1700 INJECTION, HYDROCORTISONE ACETATE, J1710 INJECTION, HYDROCORTISONE SODIUM P J1720 INJECTION, HYDROCORTISONE SODIUM S J1725 HYDROXYPROGESTERONE CAPROATE J1726 MAKENA, 10 MG J1729 INJ HYDROXYPROGST CAPOAT NOS J1730 INJECTION, DIAZOXIDE, UP TO 300 MG J1740 IBANDRONATE SODIUM INJECTION J1741 IBUPROFEN INJECTION J1742 IBUTILIDE FUMARATE INJECTION J1743 IDURSULFASE INJECTION J1744 ICATIBANT INJECTION J1745 INFLIXIMAB INJECTION J1746 INJ., IBALIZUMAB-UIYK, 10 MG J1750 INJ IRON DEXTRAN J1751 IRON DEXTRAN 165 INJECTION J1752 IRON DEXTRAN 267 INJECTION J1756 IRON SUCROSE INJECTION


TBSP10616-E (2/20)

Code Description J1785 INJECTION IMIGLUCERASE PER UNIT J1786 IMUGLUCERASE INJECTION J1790 INJECTION, DROPERIDOL, UP TO 5 MG J1800 INJECTION, PROPRANOLOL HCL, UP TO J1810 INJECTION, DROPERIDOL AND FENTANYL J1815 INSULIN INJECTION J1817 INSULIN FOR INSULIN PUMP USE J1825 INTERFERON BETA-1A J1826 INTERFERON BETA-1A INJ J1830 INTERFERON BETA-1B / .25 MG J1833 INJECTION, ISAVUCONAZONIUM J1835 INTRACONAZOLE INJECTION J1840 INJECTION, KANAMYCIN SULFATE, UP T J1850 INJECTION, KANAMYCIN SULFATE, UP T J1885 INJECTION, KETOROLAC TROMETHAMINE, 15MG J1890 INJECTION, CEPHALOTHIN SODIUM, UP J1930 *09 LANREOTIDE INJECTION J1931 LARONIDASE 0.1MG J1940 INJECTION, FUROSEMIDE, UP TO 20 MG J1942 ARIPIPRAZOLE LAUROXIL 1MG J1943 INJ., ARISTADA INITIO,1 MG J1944 INJ., ARISTADA,1 MG J1945 LEPIRUDIN J1950 INJECTION LEUPROLIDE ACETATE PER 3 J1953 LEVETIRACETAM INJECTION J1955 INJECTION, LEVOCARNITINE, PER 1 GM J1956 LEVOFLOXACIN INJECTION J1960 INJECTION, LEVORPHANOL TARTRATE, U J1980 INJECTION, HYOSCYAMINE SULFATE, UP J1990 INJECTION, CHLORDIAZEPOXIDE HCL, U J2001 LIDOCAINE INJECTION J2010 INJECTION, LINCOMYCIN HCL, UP TO 3

Code Description J2020 LINEZOLID INJECTION J2060 INJECTION, LORAZEPAM, 2 MG J2062 LOXAPINE FOR INHALATION 1 MG J2150 INJECTION, MANNITOL, 25% IN 50 ML J2170 MECASERMIN INJECTION J2175 INJECT MEPERIDINE HYDROCHLORID PER 100MG J2180 INJECTION, MEPERIDINE AND PROMETHA J2182 INJECTION, MEPOLIZUMAB, 1MG J2185 MEROPENEM J2210 INJECTION, METHYLERGONOVINE MALEAT J2212 METHYLNALTREXONE INJECTION J2248 MICAFUNGIN SODIUM INJECTION J2250 INJECT MIDAZ HYDROCHLOR PER 1 MG J2260 INJ MILRINONE LACTATE / 5 ML J2265 MINOCYCLINE HYDROCHLORIDE J2270 INJECTION, MORPHINE SULFATE, UP TO J2271 MORPHINE SO4 INJECTION 100MG J2274 IN MORPHINE PRESERVATIV FREE J2275 INJECT. MORPHINE SULFATE, PER 10 MG J2278 ZICONOTIDE INJECTION J2280 INJ, MOXIFLOXACIN 100 MG J2300 NALBUPHINE HYDROCHLORIDE, 10 MG J2310 INJECT NALOX HYDROCHLOR PER 1 MG J2315 NALTREXONE, DEPOT FORM J2320 INJECTION, NANDROLONE DECANOATE, U J2321 INJECTION, NANDROLONE DECANOATE, U J2322 INJECTION, NANDROLONE DECANOATE, U J2323 NATALIZUMAB INJECTION J2325 NESIRITIDE INJECTION J2326 INJ, NUSINERSEN, 0.1MG J2350 INJECTION, OCRELIZUMAB, 1MG J2353 OCTREOTIDE INJECTION, DEPOT


TBSP10616-E (2/20)

Code Description J2354 OCTREOTIDE INJ, NON-DEPOT J2355 OPRELVEKIN INJECTION J2357 OMALIZUMAB INJECTION 5MG J2358 OLANZAPINE LONG-ACTING INJ J2360 INJECTION, ORPHENADRINE, UP TO 60 J2370 INJECTION, PHENYLEPHRINE HCL, UP T J2400 INJECTION, CHLOROPROCAINE HCL J2405 ODANSETRON HYDROCHLORIDE, PER 1MG J2407 INJECTION, ORITAVANCIN J2410 INJECTION, OXYMORPHONE HCL, UP TO J2425 PALIFERMIN INJECTION J2426 PALIPERIDONE PALMITATE INJ J2430 INJECTION PAMIDRONATE DISODIUM PER 30MG J2440 INJECTION, PAPAVERINE HCL, UP TO 6 J2460 INJECTION, OXYTETRACYCLINE HCL, UP J2469 PALONOSETRON HCL J2501 PARICALCITOL J2502 INJ, PASIREOTIDE LONG ACTING J2503 PEGAPTANIB SODIUM INJECTION J2504 PEGADEMASE BOVINE, 25 IU J2505 INJECTION, PEGFILGRASTIM 6MG J2507 PEGLOTICASE INJECTION J2510 INJECTION, PENICILLIN G PROCAINE, J2513 PENTASTARCH 10% SOLUTION J2515 INJECTION, PENTOBARBITAL SODIUM J2540 INJECTION, PENICILLIN G POTASSIUM, J2543 PIPERACILLIN/TAZOBACTAM J2545 PENTAMIDINE NON-COMP UNIT J2547 INJECTION, PERAMIVIR J2550 INJECTION, PROMETHAZINE HCL, UP TO J2560 INJECTION, PHENOBARBITAL SODIUM, U J2562 PLERIXAFOR INJECTION

Code Description J2590 INJECTION, OXYTOCIN, UP TO 10 UNIT J2597 INJECT DESMOPR ACETATE PER 4 MCG J2650 INJECTION, PREDNISOLONE ACETATE, U J2670 INJECTION, TOLAZOLINE HCL, UP TO 2 J2675 INJ PROGESTERONE PER 50 MG J2680 INJECTION, FLUPHENAZINE DECANOATE, J2690 INJECTION, PROCAINAMIDE HCL, UP TO J2700 INJECTION, OXACILLIN SODIUM, UP TO J2704 INJ, PROPOFOL, 10 MG J2710 INJECTION, NEOSTIGMINE METHYLSULFA J2720 INJECTION, PROTAMINE SULFATE, PER 10 MG J2724 PROTEIN C CONCENTRATE J2725 INJECTION PROTIRELIN PER 250 MCG J2730 INJECTION, PRALIDOXIME CHLORIDE, U J2760 INJECTION, PHENTOLAINE MESYLATE, U J2765 INJECTION, METOCLOPRAMIDE HCL, UP J2770 QUINUPRISTIN/DALFOPRISTIN J2778 RANIBIZUMAB INJECTION J2780 RANITIDINE HYDROCHLORIDE INJ J2783 RASBURICASE J2785 REGADENOSON INJECTION J2786 INJECTION, RESLIZUMAB, 1MG J2788 RHO D IMMUNE GLOBULIN 50 MCG J2790 RHO D IMMUNE GLOBULIN INJ J2791 RHOPHYLAC INJECTION J2792 RHO(D) IMMUNE GLOBULIN H, SD J2793 RILONACEPT INJECTION J2794 INJ., RISPERDAL CONSTA, 0.5 MG J2795 ROPIVACAINE HCL INJECTION J2796 ROMIPLOSTIM INJECTION J2797 INJ., ROLAPITANT, 0.5 MG J2798 INJ., PERSERIS, 0.5 MG


TBSP10616-E (2/20)

Code Description J2800 INJECTION, METHOCARBAMOL, UP TO 10 J2805 SINCALIDE INJECTION J2810 INJECTION, THEOPHYLLINE, PER 40 MG J2820 SARGRAMOSTIM INJECTION J2840 INJ SEBELIPASE ALFA 1 MG J2850 INJ SECRETIN SYNTHETIC HUMAN J2860 INJECTION, SILTUXIMAB J2910 INJECTION, AUROTHIOGLUCOSE, UP TO J2916 NA FERRIC GLUCONATE COMPLEX J2920 INJECTION, METHYLPREDNISOLONE SODI J2930 INJECTION, METHYLPREDNISOLONE SODI J2940 SOMATREM INJECTION J2941 SOMATROPIN INJECTION J2950 INJECTION, PROMAZINE HCL, UP TO 25 J2993 RETEPLASE INJECTION J2995 INJECTION, STREPTOKINASE PER 250,000 IU J2997 ALTEPLASE RECOMBINANT J3000 INJECTION, STREPTOMYCIN, UP TO 1 G J3010 FENTANYL CITRATE INJECITON J3030 SUMATRIPTAN SUCCINATE / 6 MG J3031 INJ., FREMANEZUMAB-VFRM 1 MG J3060 INJ, TALIGLUCERACE ALFA 10 U J3070 PENTAZOCINE INJECTION, 30 MG J3090 INJ TEDIZOLID PHOSPHATE J3095 TELEVANCINTELAVANCIN INJECTION J3100 TENECTEPLASE INJECTION J3101 TENECTEPLASE INJECTION J3105 INJECTION, TERBUTALINE SULFATE, UP J3110 TERIPARATIDE INJECTION J3111 INJ. ROMOSOZUMAB-AQQG 1 MG J3120 INJECTION, TESTOSTERONE ENANTHATE, J3121 INJ TESTOSTERO ENANTHATE 1MG

Code Description J3130 INJECTION, TESTOSTERONE ENANTHATE, J3140 INJECTION, TESTOSTERONE SUSPENSION J3145 TESTOSTERONE UNDECANOATE 1MG J3150 INJECTION, TESTOSTERONE PROPIONATE J3230 INJECTION, CHLORPROMAZINE HCL, UP J3240 THYROTROPIN INJECTION J3243 TIGECYCLINE INJECTION J3246 TIROFIBAN HCL J3250 INJECTION, TRIMETHOBENZAMIDE HCL, J3260 INJECTION, TOBRAMYCIN SULFATE, UP J3262 TOCILIZUMAB INJECTION J3265 INJECTION, TORSEMIDE, 10 MG/ML J3280 INJECTION, THIETHYLPERAZINE MALEAT J3285 TREPROSTINIL INJECTION J3300 TRIAMCINOLONE A INJ PRS-FREE J3301 INJECTION TRIAMCINOLONE ACETONIDE, J3302 INJECTION TRIAMCINOLONE DIACETATE, J3303 INJECTION TRIAMCINOLONE HEXACETONI J3304 INJ TRIAMCINOLONE ACE XR 1MG J3305 INJECT TRIMET GLUCORONATE, PER 25 MG J3310 INJECTION, PERPHENAZINE, UP TO 5 M J3315 TRIPTORELIN PAMOATE J3316 INJ., TRIPTORELIN XR 3.75 MG J3320 INJECTION, SPECTINOMYCIN DIHYDROCH J3350 INJECTION, UREA, UP TO 40 GM J3355 UROFOLLITROPIN, 75 IU J3357 USTEKINUMAB INJECTION J3358 USTEKINUMAB, IV INJECT, 1 MG J3360 INJECTION, DIAZEPAM, UP TO 5 MG J3364 INJECTION, UROKINASE, 5000 I.U PER VIAL J3365 INJECTION, IV, UROKINASE, 250,000 J3370 VANCOMYCIN HCL INJECITON


TBSP10616-E (2/20)

Code Description J3380 INJECTION, VEDOLIZUMAB J3385 VELAGLUCERASE ALFA J3396 VERTEPORFIN INJECTION J3398 INJ LUXTURNA 1 BILLION VEC G J3400 INJECTION, TRIFLUPROMAZINE HCL, UP J3410 INJECTION, HYDROXYZINE HCL, UP TO J3411 THIAMINE HCL 100 MG J3415 PYRIDOXINE HCL 100 MG J3420 INJECTION, VITAMIN B 12 CYANOCOBA J3430 INJECTION, VITAMIN K, PHYTONADIONE J3465 INJECTION, VORICONAZOLE J3470 INJECTION, HYALURONIDASE, UP TO 15 J3471 OVINE, UP TO 999 USP UNITS J3472 OVINE, 1000 USP UNITS J3473 HYALURONIDASE RECOMBINANT J3475 INJECTION, MAGNESIUM SULFATE, PER 500 MG J3480 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ J3485 ZIDOVUDINE J3486 ZIPRASIDONE MESYLATE J3487 ZOLEDRONIC ACID J3488 RECLAST INJECTION J3489 ZOLEDRONIC ACID 1MG J3490 UNCLASSIFIED DRUGS J3520 ENDRATE ETHYLENEDIAMINE-TETRA-ACET J3530 NASAL VACCINE INHALATION J3535 DRUG ADMIN THRU METERED DOSE INHALER J3590 UNCLASSIFIED BIOLOGICS J3591 ESRD ON DIALYSI DRUG/BIO NOC J7030 INFUSION, NORMAL SALINE SOLUTION , J7040 INFUSION, NORMAL SALINE SOLUTION, J7042 5% DEXTROSE/NORMAL SALINE (500 ML J7050 INFUSION, NORMAL SALINE SOLUTION ,

Code Description J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT J7070 INFUSION, D5W, 1000 CC J7100 INFUSION, DEXTRAN 40, 500 ML J7110 INFUSION, DEXTRAN 75, 500 ML J7120 RINGERS LACTATE INFUSION, UP TO 10 J7121 5% DEXTROSE IN LAC RINGERS J7170 INJ., EMICIZUMAB-KXWH 0.5 MG J7175 INJ, FACTOR X, (HUMAN), 1 IU J7178 HUMAN FIBRINOGEN CONC INJ J7179 VONVENDI INJ 1 IU VWF: RCO J7180 FACTOR XIII ANTI-HEM FACTOR J7181 FACTOR XIII RECOMB A-SUBUNIT J7182 FACTOR VIII RECOMB NOVOEIGHT J7183 WILATE INJECTION J7184 WILATE INJECTION J7185 XYNTHA INJ J7186 ANTIHEMOPHILIC VIII/VWF COMP J7187 HUMATEP, INJ J7188 FACTOR VIII RECOMB OBIZUR J7189 FACTOR VIIA J7190 FACTOR VIII J7192 FACTOR VIII RECOMBINANT J7193 FACTOR IX NONRECOMBINANT J7194 HEATTREATED AHF IX J7195 FACTOR IX RECOMBINANT J7196 ANTITHROMBIN RECOMBINANT J7197 ANTITHROMBIN III (HUMAN), PER I.U. J7198 ANTI-INHIBITOR J7200 FACTOR IX RECOMBINAN RIXUBIS J7201 FACTOR IX FC FUSION RECOMB J7202 FACTOR IX IDELVION INJ J7203 FACTOR IX RECOMB GLY REBINYN


TBSP10616-E (2/20)

Code Description J7205 FACTOR VIII FC FUSION RECOMB J7207 FACTOR VIII PEGYLATED RECOMB J7208 FACTOR VIII, PEGYLATED-AUCL J7209 FACTOR VIII NUWIQ RECOMB 1 IU J7210 INJ, AFSTYLA, 1 I.U. J7211 INJ, KOVALTRY, 1 I.U. J7297 LEVONORGESTREL IU 52MG 3 YR J7298 LEVONORGESTREL IU 52MG 5 YR J7300 INTRAUTERINE COPPER CONTRACEPTIVE J7301 SKYLA 13.5MG J7302 LEVONORGESTREL IU CONTRACEPT J7303 CONTRACEPTIVE VAGINAL RING J7304 CONTRACEPTIVE HORMONE PATCH J7307 ETONOGESTREL IMPLANT SYSTEM J7308 AMINOLEVULINIC ACID HCL TOP J7309 METHYL AMINOLEVULINATE, TOP J7310 GANCICLOVIR LONG ACT IMPLANT J7311 FLUOCINOLONE ACETONIDE IMPLT J7312 DEXAMETHASONE INTRA IMPLANT J7313 INJ., ILUVIEN, 0.01 MG J7314 INJ., YUTIQ, 0.01 MG J7315 OPTHALMIC MITOMYCIN J7316 OCRIPLASMIN 0.125 MG J7318 INJ, DUROLANE 1 MG J7328 GEL-SYN INJECTION 0.1 MG J7329 INJ, TRIVISC 1 MG J7331 SYNOJOYNT, INJ., 1 MG J7332 INJ., TRILURON, 1 MG J7335 CAPSAICIN 8% PATCH J7336 CAPSAICIN 8% PATCH J7340 CARBIDOPA LEVODOPA ENT 100ML J7342 CIPROFLOXACIN OTIC SUSP 6 MG

Code Description J7345 AMINOLEVULINIC ACID, 10% GEL J7401 MOMETASONE FUROATE SINUS IMP J7500 AZATHIOPRINE ORAL 50MG J7501 AZATHIOPRINE PARENTERAL J7502 CYCLOSPORINE, ORAL, 100 MG J7503 TACROL ENVARSUS EX REL ORAL J7504 LYMPHOCYTE IMMUNE GLOBULIN J7505 MONOCLONAL ANTIBODIES J7506 PREDNISONE, ANY DOSAGE, 100 TABLET J7507 TACROLIMUS ORAL PER 1 MG J7508 TACROLIMUS EX REL ORAL 0.1MG J7509 METHYLPREDNISOLONE ORAL, PER 4 MG J7510 PREDNISOLONE ORAL, PER 5 MG J7511 ANTITHYMOCYTE GLOBULN RABBIT J7512 PREDNISONE IR OR DR ORAL 1MG J7513 DACLIZUMAB, PARENTERAL J7515 CYCLOSPORINE ORAL 25 MG J7516 CYCLOSPORIN PARENTERAL 250MG J7517 MYCOPHENOLATE MOFETIL ORAL J7518 MYCOPHENOLIC ACID J7520 SIROLIMUS, ORAL J7525 TACROLIMUS INJECTION J7527 ORAL EVEROLIMUS J7599 IMMUNOSUPPRESIVE DRUG NOT OTHERW CLASSIF J7602 ALBUTEROL INH NON-COMP CON J7603 ALBUTEROL INH NON-COMP U D J7605 ARFORMOTEROL NON-COMP UNIT J7606 FORMOTEROL FUMARATE, INH J7608 ACETYLCYSTEINE NON-COMP UNIT J7611 ALBUTEROL NON-COMP CON J7612 LEVALBUTEROL NON-COMP CON J7613 ALBUTEROL NON-COMP UNIT


TBSP10616-E (2/20)

Code Description J7614 LEVALBUTEROL NON-COMP UNIT J7620 ALBUTEROL IPRATROP NON-COMP J7626 BUDESONIDE NON-COMP UNIT J7631 CROMOLYN SODIUM NONCOMP UNIT J7633 BUDESONIDE NON-COMP CON J7639 DORNASE ALFA NON-COMP UNIT J7644 IPRATROPIUM BROMIDE NON-COMP J7648 ISOETHARINE NON-COMP CON J7649 ISOETHARINE NON-COMP UNIT J7658 ISOPROTERENOL NON-COMP CON J7659 ISOPROTERENOL NON-COMP UNIT J7665 MANNITOL FOR INHALER J7668 METAPROTERENOL NON-COMP CON J7669 METAPROTERENOL NON-COMP UNIT J7674 METHACHOLINE CHLORIDE, NEB J7677 REVEFENACIN INH NON-COM 1MCG J7682 TOBRAMYCIN NON-COMP UNIT J7686 TREPROSTINIL, NON-COMP UNIT J7699 NOC DRUGS, INHALATION SOLUTION J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS J7999 COMPOUNDED DRUG, NOC J8498 ANTIEMETIC RECTAL/SUPP NOS J8499 PRESCRIPTION DRUG ORAL NON CHEMOTHERAPEU J8501 ORAL APREPITANT J8510 ORAL BUSULFAN J8515 CABERGOLINE, ORAL 0.25MG J8520 CAPECITABINE, ORAL, 150 MG J8521 CAPECITABINE, ORAL, 500 MG J8530 CYCLOPHOSPHAMIDE ORAL 25 MG J8540 ORAL DEXAMETHASONE J8560 ETOPOSIDE ORAL 50 MG J8561 ORAL EVEROLIMUS

Code Description J8562 ORAL FLUDARABINE PHOSPHATE J8565 GEFITINIB ORAL J8597 ANTIEMETIC DRUG ORAL NOS J8600 MELPHALAN ORAL 2 MG J8610 METHOTREXATE ORAL 2.5 MG J8650 NABILONE ORAL J8655 NETUPITANT PALONOSETRON ORAL J8670 ROLAPITANT, ORAL, 1MG J8700 TEMOZOLMIDE J8705 TOPOTECAN ORAL J8999 PRESCRIPTION DRUG ORAL CHEMOTHERAPEUTIC J9000 DOXORUBICIN HCL, 10 MG J9001 DOXORUBICIN HCL LIPOSOME INJ J9002 DOXIL INJECTION J9010 ALEMTUZUMAB INJECTION J9015 ALDESLEUKIN INJECTION J9017 ARSENIC TRIOXIDE INJECTION J9019 ERWINAZE INJECTION J9020 ASPARAGINASE INJECTION J9022 INJ, ATEZOLIZUMAB,10 MG J9023 INJECTION, AVELUMAB, 10 MG J9025 AZACITIDINE 1MG J9027 CLOFARABINE, 1 MG J9030 BCG LIVE INTRAVESICAL 1MG J9031 BCG (INTRAVESICAL) PER INSTALLATIO J9032 INJECTION, BELINOSTAT, 10MG J9033 BENDAMUSTINE INJECTION J9034 INJ., BENDEKA 1 MG J9035 BEVACIZUMAB INJECTION J9036 INJ., BELRAPZO, 1 MG J9039 INJECTION, BLINATUMOMAB J9040 BLEOMYCIN SULFATE, 15 UNITS


TBSP10616-E (2/20)

Code Description J9041 BORTEZOMIB INJECTION J9042 BRENTUXIMAB VEDOTIN INJ J9043 CABAZITAXEL INJECTION J9044 INJ, BORTEZOMIB, NOS, 0.1 MG J9045 CARBOPLATIN 50 MG J9047 INJECTION, CARFILZOMIB, 1 MG J9050 CARMUSTINE, 100 MG J9055 CETUXIMAB, 10MG J9057 INJ., COPANLISIB, 1 MG J9060 CISPLATIN 10 MG INJECTION J9062 CISPLATIN, 50 MG VIAL J9065 INJECTION CLADRIBINE PER 1 MG J9070 CYCLOPHOSPHAMIDE, 100 MG J9080 CYCLOPHOSPHAMIDE, 20 CC OR 200 MG J9090 CYCLOPHOSPHAMIDE, 30 CC OR 500 MG J9091 CYCLOPHOSPHAMIDE, 1.0 GRAM J9092 CYCLOPHOSPHAMIDE, 2.0 GRAM J9093 CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 J9094 CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 J9095 CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 J9096 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 J9097 CYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 J9098 CYTARABINE LIPOSOME J9100 CYTARABINE 100 MG J9110 CYTARABINE HCL, 500 MG J9118 INJ. CALASPARGASE PEGOL-MKNL J9119 INJ., CEMIPLIMAB-RWLC, 1 MG J9120 DACTINOMYCIN, 0.5MG J9130 DACARBAZINE 100 MG INJ J9140 DACARBAZINE, 10 MG/ML (200 MG VIAL J9145 INJECTION, DARATUMUMAB 10 MG J9150 DAUNORUBICIN

Code Description J9151 DAUNORUBICIN CITRATE LIPOSOM J9155 DEGARELIX INJECTION J9160 DENILEUKIN DIFTITOX, 300 MCG J9165 DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG J9171 DOCETAXEL INJECTION J9173 INJ., DURVALUMAB, 10 MG J9175 ELLIOTTS B SOLUTION PER ML J9176 INJECTION, ELOTUZUMAB, 1MG J9178 INJ, EPIRUBICIN HCL, 2 MG J9179 ERIBULIN MESYLATE INJECTION J9181 ETOPOSIDE 10 MG. J9182 ETOPOSIDE, UP TO 100 MG. J9185 FLUDARABINE PHOSPHATE, 50 MG J9190 FLUOROURACIL, 500 MGM AMP J9199 INJECTION, INFUGEM, 200 MG J9200 FLOXURIDINE, 500 MG J9201 IN GEMCITABINE HCL NOS 200MG J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 J9203 GEMTUZUMAB OZOGAMICIN 0.1 MG J9204 INJ, MOGAMULIZUMAB-KPKC, 1 MG J9205 INJ IRINOTECAN LIPOSOME 1 MG J9206 IRINOTECAN INJECTION J9207 IXABEPILONE INJECTION J9208 IFOSFAMIDE INJECTION J9209 MESNA, 200 MG. J9210 INJ., EMAPALUMAB-LZSG, 1 MG J9211 IDARUBICIN HYDROCHLORIDE, 5MG J9212 *99 INTERFERON ALFACON-1 J9213 INTERFERON ALFA2A, RECOMBINANT 3 MILL U J9214 INTERFERON ALFA2B, RECOMBINANT 1 MILL U J9215 INTERFERON, ALFAN3 250,000 IU J9216 INTERFERON, GAMMA 1B, 3 MILLION UNITS


TBSP10616-E (2/20)

Code Description J9217 LEUPROLIDE ACETATE, FOR DEPOT SUSP 7.5MG J9218 LEUPROLIDE ACETATE, PER 1 MG J9219 LEUPROLIDE ACETATE IMPLANT J9225 VANTAS IMPLANT J9226 SUPPRELIN LA IMPLANT J9228 IPILIMUMAB INJECTION J9230 MECHLORETHAMINE HCL, (NITRO MUSTARD) 10MG J9245 INJECTION MELPHALAN HYDROCHILORIDE50MG J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 J9260 METHOTREXATE SODIUM, 50MG J9261 NELARABINE INJECTION J9262 INJ, OMACETAXINE MEP, 0.01MG J9263 OXALIPLATIN 0.5 MG J9264 PACLITAXEL PROTEIN BOUND J9265 PACLITAXEL, 30 MG J9266 PEGASPARGASE, PER SINGLE DOSE VIAL J9267 PACLITAXEL INJECTION J9268 PENTOSTATIN, PER 10 MG J9269 INJ. TAGRAXOFUSP-ERZS 10 MCG J9270 PLICAMYCIN 2.5 MG J9271 INJ PEMBROLIZUMAB J9280 MITOMYCIN, 5 MG J9285 INJ, OLARATUMAB, 10 MG J9290 MITOMYCIN, 20 MG J9291 MITOMYCIN, 40 MG J9293 MITOXANTRONE HYDROCHLORIDE PER 5 MG J9295 INJECTION, NECITUMUMAB, 1 MG J9299 INJECTION, NIVOLUMAB, 1 MG J9300 GEMTUZUMAB OZOGAMICIN, 5MG J9301 OBINUTUZUMAB INJ J9302 OFATUMUMAB INJECTION J9303 PANITUMUMAB INJECTION

Code Description J9305 PEMETREXED 10 MG INJECTION J9306 INJECTION, PERTUZUMAB, 1 MG J9307 PRALATREXATE INJECTION J9308 INJECTION, RAMUCIRUMAB J9309 INJ, POLATUZUMAB VEDOTIN 1MG J9310 RITUXIMAB 100 MG J9311 INJ RITUXIMAB, HYALURONIDASE J9312 INJ., RITUXIMAB, 10 MG J9313 INJ., LUMOXITI, 0.01 MG J9315 ROMIDEPSIN INJECTION J9320 STREPTOZOCIN, 1GM J9325 INJ TALIMOGENE LAHERPAREPVEC J9328 TEMOZOLOMIDE INJECTION J9330 TEMSIROLIMUS INJECTION J9340 THIOTEPA, 15 MG J9350 TOPOTECAN, 4 MG J9351 TOPOTECAN INJECTION J9352 INJECTION TRABECTEDIN 0.1MG J9354 INJ, ADO-TRASTUZUMAB EMT 1MG J9355 INJ TRASTUZUMAB EXCL BIOSIMI J9356 INJ. HERCEPTIN HYLECTA, 10MG J9357 VALRUBICIN, 200 MG J9360 VINBLASTINE SULFATE, 1 MG J9370 VINCRISTINE SULFATE, 1 MG J9371 INJ, VINCRISTINE SUL LIP 1MG J9375 VINCRISTINE SULFATE 2 MG/2 ML (2 M J9380 VINCRISTINE SULFATE, 5 MG/5 ML (5 J9390 VINORELBINE TARTRATE, PER 10 MG J9395 INJECTION, FULVESTRANT J9400 INJ, ZIV-AFLIBERCEPT, 1MG J9600 PORFIMER SODIUM J9999 NOT OTHERWISE CLASSIFIED, ANTINEOP


TBSP10616-E (2/20)

Code Description P9041 ALBUMIN (HUMAN), 5%, 50ML P9043 PLASMA PROTEIN FRACT, 5%, 50ML P9045 ALBUMIN (HUMAN), 5%, 250 ML P9046 ALBUMIN (HUMAN), 25%, 20 ML P9047 ALBUMIN (HUMAN), 25%, 50ML P9048 PLASMAPROTEIN FRACT, 5%, 250ML P9099 BLOOD COMPONENT/PRODUCT NOC Q0090 LEVONORGESTREL INTRAUTERINE CONTRACEPTIV Q0138 FERUMOXYTOL, NON-ESRD Q0139 FERUMOXYTOL, ESRD USE Q0144 AZITHROMYCIN DIHYDRATE, ORAL Q0161 FACTOR IX RECOMBINANT Q0162 ONDANSETRON ORAL Q0163 DIPHENHYDRAMINE HCL 50MG Q0164 PROCHLORPERAZINE MALEATE 5MG Q0165 PROCHLORPERAZINE MALEATE10MG Q0166 GRANISETRON HCL 1 MG ORAL Q0167 DRONABINOL 2.5MG ORAL Q0168 DRONABINOL 5MG ORAL Q0169 PROMETHAZINE HCL 12.5MG ORAL Q0170 PROMETHAZINE HCL 25 MG ORAL Q0171 CHLORPROMAZINE HCL 10MG ORAL Q0172 CHLORPROMAZINE HCL 25MG ORAL Q0175 PERPHENAZINE 4MG ORAL Q0176 PERPHENAZINE 8MG ORAL Q0177 HYDROXYZINE PAMOATE 25MG Q0178 HYDROXYZINE PAMOATE 50MG Q0179 ONDANSETRON HCL 8 MG ORAL Q0180 DOLASETRON MESYLATE ORAL Q0181 UNSPECIFIED ORAL ANTI-EMETIC Q0515 SERMORELIN ACETATE INJECTION Q2009 FOSPHENYTOIN INJ PE

Code Description Q2017 TENIPOSIDE, 50 MG Q2023 XYNTHA, FACTOR VIII Q2040 TISAGENLECLEUCEL CAR-POS T Q2041 AXICABTAGENE CILOLEUCEL CAR Q2042 TISAGENLECLEUCEL CAR-POS T Q2043 SIPULEUCEL-T Q2044 BELIMUMAB Q2045 HUMAN FIBRINOGEN CONC INJ 1 MG Q2046 AFLIBERCEPT INJECTION 1 MG Q2047 PEGINESATIDE 0.1 MG-FOR ERSD ON DIALYSIS Q2048 DOXORUBICIN HCL, LIPOSOMAL, DOXIL 10 MG Q2049 DOXORUBICIN HCL, LIPOSOMAL,LIPODOX 10MG Q2050 DOXORUBICIN HCL LIPOSOMAL Q2051 ZOLEDRONIC ACID 1MG(NOT OTHERWISE SPEC) Q3025 IM INJ INTERFERON BETA 1-A Q3026 SUBC INJ INTERFERON BETA-1A Q3027 BETA INTERFERON IM 1 MCG Q3028 BETA INTERFERON SQ 1 MCG Q4074 ILOPROST NON-COMP UNIT DOSE Q4080 ILOPROST NON-COMP UNIT DOSE Q4081 EPOETIN ALFA, 100 UNITS ESRD Q4082 DRUG/BIO NOC PART B DRUG CAP Q4097 INJ IVIG PRIVIGEN 500 MG Q4098 INJ IRON DEXTRAN Q5101 INJECTION, ZARXIO Q5103 INJECTION, INFLECTRA Q5104 INJECTION, (RENFLEXIS), 10MG Q5105 INJ RETACRIT ESRD ON DIALYSI Q5106 INJ RETACRIT NON-ESRD USE Q5108 INJECTION, FULPHILA Q5109 INJECTION, IXIFI, 10 MG Q5110 NIVESTYM


TBSP10616-E (2/20)

Code Description Q5111 INJECTION, UDENYCA 0.5 MG Q5112 INJ ONTRUZANT 10 MG Q5113 INJ HERZUMA 10 MG Q5114 INJ OGIVRI 10 MG Q5115 INJ RITUXIMAB-ABBS BIO 10 MG Q5116 INJ., TRAZIMERA, 10 MG Q5117 INJ., KANJINTI, 10 MG Q5118 INJ., ZIRABEV, 10 MG Q9970 FERRIC CARBOXYMALTOSE 1MG, INJECTION Q9974 INJ MORPHINE SULFATE 10MG Q9975 FACTOR VIII, FC FUSION PROTEIN Q9976 INJ FERRIC PYROPHOSPHATE CIT Q9977 COMPOUNDED DRUG NOC Q9978 ORAL, NETUPITANT PALONOSETRON Q9979 INJECTION, ALEMTUZUMAB 1 MG Q9984 KYLEENA Q9985 INJ, HYDROXYPROGESTERONE, NOS, 10MG Q9986 INJ., MAKENA Q9989 USTEKINUMAB IV INJ. 1MG Q9991 BUPRENORPH XR 100 MG OR LESS Q9992 BUPRENORPHINE XR OVER 100 MG Q9993 INJ., TRIAMCINOLONE EXT REL Q9995 INJ. EMICIZUMAB-KXWH, 0.5 MG S0017 AMINOCAPROIC ACID S0020 BUPIVACAINE HCL 30 CC S0032 INJECTION, NAFCILLIN SODIUM S0077 INJECTION, CLINDAMYCIN PHOSP S0080 PENTAMIDINE ISETHIONATE 300 MG S0109 METHADONE ORAL 5MG S0117 TRETINOIN TOPICAL 5 G S0140 SAQUINAVIR, 200 MG S0141 ZALCITABINE, 0.375 MG

Code Description S0142 COLISTIMETHATE INH SOL MG S0143 AZTREONAM INH SOL GRAM S0144 INJECTION, PROPOFOL, 10 MG S0145 PEG INTERFERON ALFA2A/180 S0148 PEG INTERFERON ALFA-2B/10 S0164 INJECTION PANTOPRAZOLE S0166 INJ OLANZAPINE 2.5 MG S0169 CALCITROL S0189 TESTOSTERONE PELLET 75 MG S0190 MIFEPRISTONE, ORAL, 200 MG S0191 MISOPROSTOL, ORAL, 200 MCG S0197 PRENATAL VITAMINS 30 DAY S4989 CONTRACEPTIVE INTRAUTERINE S4993 CONTRACEPTIVE PILLS FOR BC S5000 PRESCRIPTION DRUG, GENERIC S5001 PRESCRIPTION DRUG, BRAND NAME X1522 PARAGARD INTRAUTERINE DEVICE X1532 MIRENA INTRAUTERINE SYSTEM X5500 ACETAZOLAMIDE-500MG(DIAMOX) X5501 ZEMPLAR 5MCG X5503 ZEMPLAR INJECTION 2MCG X5505 HECTOROL 2MCG X5507 HECTOROL 4MCG X5509 TINZAPARIN SODIUM, 1000 IU/CC INJ. X5514 ACTH-25UNITS DRY PWD/VIAL X5516 ACTH(OR)CORTICOTROPIN-80UNITS/ML X5518 ACTH(OR)CORTICOTROPIN-40UNITS/ML X5520 ACTH(OR)CORTICOTROPIN-25UNITS/ML X5522 ADENOSINE PHOSPHATE-25MG/ML(ADENOCREST X5528 EPINEPHRINE HCL-1MG/ML (ADRENALIN CHLORID X5530 EPINEPHRINE PNT-1:1000 SOL (ADRENAL CHLOR X5534 POLYMYXIN B SULFATE-500,000 UNITS


TBSP10616-E (2/20)

Code Description X5536 BIPERIDEN-5MG/ML(AKINETON) X5540 METHYDOLPA/METHYLDOPATE HCL-25MG/ML/5ML X5550 AMPICILLIN SOD-PARENTERAL-125MG PWD VIAL X5552 TRIAMCINOLONE-40MG/ML SUSPENSION X5554 METHYLPREDNISOLONE SOD SUCCINATE40MG/ML X5556 AMINOCAPROIC ACID-250MG/ML(AMICAR) X5558 AMIKACIN SULFATE-1GM/4ML VIAL(AMIKIN) X5560 AMIKACIN SULFATE-100MG/2ML VIAL(AMIKIN) X5562 AMIKACIN SULFATE-500MG/ML VIAL(AMIKIN) X5564 AMITRIPTYLINE HCL-10MG/ML (ELAVIL HCL) X5566 AMOBARBITAL SOD-500MG (AMYTAL SOD) X5572 AMPHOTERICIN B-50MG/ML (FUNGIZONE I.V.) X5576 AMPICILLIN SOD PAR-2G PWD PIGGYBACK UNIT X5578 AMPICILLIN SOD PARENTAL-2G PWD VIALS X5580 AMPICILLIN SOD PARENTAL-1G PWD PIGGYBACK X5582 AMPICILLIN SOD PARENTAL-1G PWD VIALS X5584 AMPICILLIN SOD PARENTAL-5007G PWD VIALS X5586 AMPICILLIN SOD PARENTAL-500MG PWD VIALS X5588 AMPICILLIN SOD PARENTAL-250MG PWD VIALS X5598 NANDROLONE PHENPROPINATE-50MG/ML(OIL) X5600 NANDROLONE DECANOATE-100MG/ML(OIL) X5602 CEFAZOLIN SODIUM-10G/100ML VIAL(ANCEF) X5604 CEFAZOLIN SODIUM-1G/REDI VIAL(ANCEF) X5606 CEFAZOLIN SODIUM-1G/100ML PIGGYBACK UNIT X5608 CEFAZOLIN SODIUM-1G/10ML VIAL (ANCEF) X5610 CEFAZOLIN SODIUM/500MG/100 VIA L(ANCEF) X5612 CEFAZOLIN SODIUM-500MG/10ML VIAL (ANCEF) X5614 CEFAZOLIN SODIUM-250MG/10ML VIAL (ANCEF) X5618 TESTOSTERONE CYPIONATE-100MG/ML X5620 TESTOSTERONE CYPIONATE/ESTRADIOL X5622 CHORIONIC GONADOTROPIN(HCG)1000 UNITS/ML X5626 TESTOSTERONE ENANTHATE-100MG/ML

Code Description X5628 TESTOSTERONE-50MG/ML X5632 NANDROLONE DECANDATE-50MG/ML(OIL) X5634 TESTOSTERONE ENANTHATE-200MG/ML X5636 SUCCINYLCHOLINE CHLORIDE-20MG/ML(A.Q.S) X5640 PHYSOSTIGMINE SALICYLATE-1MG/ML(ANTILLIR X5642 DICYCLOMINE HCL-10MG/ML X5644 CHORIONIC GONADOTRIPIN(HCG)500 UNITS/ML X5646 CHORIONIC GONADOTROPIN(HCG)2000 UNITS/ML X5648 HYDRALAZINE HCL-20MG/ML(APRESOLINE) X5650 PHYTONADIONE(K-1) METH-NAPTH-10MG/ML X5652 PHYTONADIONE(K-1) METH-NAPTH-2MG/ML X5654 VITAMIN A-50,000 IU/ML(AQUASOL) X5656 CHLOROQUINE HCL 50MG/ML(ARALAN) X5658 METARAMINOL-10MG/ML (1%)(AS BITARTRATE) X5660 ESTRADIOL VALERATE IN OIL-20MG/ML X5662 ESTRADIOL VALERATE IN OIL-10MG/ML X5666 TESTIN-ENANTHATE-ESTRA VALCRATE-90MG4MC X5672 ARISTOSPAN 20 MG/CC - 5CC VIAL X5674 ARISTOSPAN 5MG/CC - 5CC VIAL X5676 TETANOS IMMUNE GLOBULIN(HUMAN)250 UNIT X5678 SODIUM THIOSALICYLATE - 50MG/CC VIAL X5680 ASCORBIC ACID-500MG/ML(CEVALIN) X5682 ASCORBIC ACID-250 MG/ML X5694 ATROPINE SULFATE-1.0 MG/ML X5698 ATROPINE SULFATE-0.5 MG/ML X5700 ALROPHINE SULFATE-0.4 MG/ML X5704 ATROPINE SULFATE-0.1MG/ML X5708 AUROTHIOGLUCOSE-50MG/ML (SOLGANAL) X5716 BACITRACIN IM-50,000 UNIT VIALS X5718 BACITRACIN IM-10,000 UNIT VIAL X5720 OXACILLIN SOD-4G PWD VIAL (PROSTAPHLIN X5722 OXACILLIN SOD-2G PWD VIAL (PROSTAPHLIN


TBSP10616-E (2/20)

Code Description X5724 OXACILLIN SOD-1G PWD VIAL (PROSTAPHLIN X5726 OXACILLIN SOD-500MG PWD VIAL (PROSTAPHLIN X5728 DIMERCAPROL-100MG/ML (BAL IN OIL) X5738 DIPHEN YDRAMINE HCL-50MG/ML(BENADRYL) X5740 DIPHENHYDRAMINE HCL (BENADRYL-BENAHIST-10 X5744 BENZTROPINE MESYLATE-1MG/ML (COGENTIN) X5750 BERROCCA-C-2 ML X5752 CYANOCOBALAMIN CRYSTALLINE-1000MCG/ML X5762 BETHANECHOL CHLORIDE 5MG/ML X5764 PENICILLIN G BENZATHINE 900,000 300000 X5766 PENICILLIN G BENZATHINE/PRO/300,000 UNIT X5768 PENICILLIN G BENZATHINE/PRO-150,000 UNIT X5770 PENICILLIN G BENZATHINE PAR 600,000 UNIT X5772 PENICILLIN G BENZATHINE PAR 300,000 UNIT X5774 HYDROCORTISONE ACETATE-50MG/ML-SUSP X5776 TERBUTALINE SUL-1MG/ML (BRETHINE BRIC SUB X5778 BRETYLIUM TOSYLATE-50MG/ML (BRETYLOL) X5780 METHOHEXITAL SOD-5G(BREVITAL SOD X5782 METHOHEXITAL SOD-2.5G/BREVITAL SOD X5784 METHOHEXITAL SOD-500MG/ML (BREVITAL SOD) X5786 BROMPHENIRAMINE MALEATE/10 MG/ML X5790 BUPIVACAINE HCL-0.75% (MARCAINE) X5792 BUPIVACAINE HCL-0.25% (MARCAINE HCL) X5794 BUPIVACAINE HCL-0.5% X5796 BUTORPHANOL TARTRATE-2MG/ML (STADOL) X5798 BUTORPHANOL TARTRATE-1MG/ML (STADOL) X5800 CAFFEINE-SOD BENZOATE-250MG/CC X5802 VIT D-500,000IU D2/ML (CAL VIT D2) X5804 CALCILONIN-400MCR UNITS (CALCIMAR) X5808 CALCIUM DISODIUM EDETATE-200MG/ML X5810 CAPREOMYCIN SUL-1GM/5CC (CAPASTAT) X5818 MEPIVACAINE HCL-2% (CARBOCAINE)

Code Description X5820 MEPIVACAINE HCL-1.5% (CARBOCAINE) X5822 MEPIVACAINE HCL-1% (CARBOCAINE X5824 MEPIVACAINE HCL-3% (CARBOCAINE HCL X5840 CEFAMANDOLE NAFATE-500MG/10ML VIAL X5842 CEFAMANDOLE NAFATE-2G/100ML VIAL(MANDOL) X5844 CEFAMANDOLE NAFATE-2G/20ML VIAL(MANDOL) X5846 CAFAMNDOLE NAFATE-1G100ML VIAL(MANDOL) X5848 CEFAMANDOLE NAFATE-1G/10ML VIAL(MANDOL) X5852 CEFONICID, SODIUM, 1GM X5854 CEFOXITIN SODIUM-2G/VIAL (MEFO XIN) X5856 CEFOXITIN SODIUM-1G/VIAL (MEFOXIN) X5858 SODIUM CEFTRIAZONE 2GM X5860 SODIUM CEFTRIAXONE 1GM X5862 SODIUM CEFTRIAXONE 500 MGM X5864 SODIUM CEFTRIAXONE 250MGM X5872 CELESTONE PHOSPHTATE X5876 CELESTONE SOLUSPAN X5878 CELESTONE SOLUSPAN-6MG/CC - 5CC X5880 TRIAMCINOLONE ACETATE-40MG/ML SUSP X5882 SODIUM ASCORBATE-500 MG/ML (CENOLATE) X5888 CEPHALOTHIN SODIUM-20G/200ML VIAL (KEFLIN X5890 CEPHALOTHIN SODIUM-4G/50ML VIAL(KEFLIN) X5892 CEPHALOTHIN SODIUM-2G/100ML VIAL(KEFLIN) X5894 CEPHALOTIN SODIUM-2G/20ML VIAL(KEFLIN) X5896 CEPHALOTHIN SODIUM-1G/100ML VIAL(KEFLIN) X5898 CEPHALOTHIN SODIUM-1G/10 ML VIAL/KEFLIN) X5912 SODIUM ASCORBATE-250MG/ML (CEVITA) X5918 CHLORPROMAZINE HCL-25MG/ML X5920 CHLORDIAZEDOXIDE-100MG/5ML (LIBRUIM) X5922 CHLORAMPHENICOL-1G/VIAL AS DRY POWDER X5924 CHLOROPROCAINE HCL-3% (NESACAINE-CE) X5926 CHLOROPROCAINE HCL-2% (NESACAINE


TBSP10616-E (2/20)

Code Description X5928 CHLOROPROCAINE HCL-1% (NESACAINE) X5930 CHLOROTHIAZIDE-500MG/20ML (DIURIL) X5932 CHLORPHENIRAMINE MALEATE-10 MG X5942 PRICOCAINE HCL-4% 1:200,000EPINEPHINE X5944 PRICOCAINE HCL-4% (CITANEST HCL) X5956 CLINDAMYCIN-600MG (AS PHOSPHATE/4ML AMPUL X5958 CLINDAMYCIN-300MG (AS PHOSPHATE/2ML AMPUL X5960 CODEINE-60MG/ML (CODEINE PHOSPHATE) X5962 CODEINE-30MG/ML (CODEINE PHOSPHATE) X5964 COLCHICINE-1MG/2ML X5966 COLISTIMETHATE SODIUM-150MG COLISTIN/ X5970 PROCHLORPERAZINE-5MG/ML (COMPAZINE) X5972 CONJUGATED ESTROGENS-25MG( PREMARIN IV) X5974 HYDROXYPROGESTERONE 250MG/CC (DELALUTIN) X5980 HYDROCORTISONE-50MG/ML (CORTEF) X5984 CORTISONE ACETATE-50MG/ML(CORTONE ACETAT X5988 HYDROCORTISONE ACETATE-25MG/ML SUSPENSIO X5998 PENICILLIN G PROCAINE AQUEOUS 300,000 X6002 DECADRON PHOSPHATE-24MG/ML X6004 DEXAMETHASONE SOD PHOSPHATE-4MG/ML X6006 DECADRON W/XYLOCAINE X6008 DEXAMETHASONE (AS ACETATE-8MG/ML X6012 DEFEROXAMINE MESYLATE-500MG/AMPUL X6014 PRENISOLONE ACETATE-25MG/ML X6018 ESTRADIOL VALERATE IN OIL-40MG/ML X6020 MEPERIDINE HCL-100MG/ML(DEMEROL HCL) X6022 MEPERINDINE HCL-75MG/ML(DEMEROL HCL) X6024 MEPHRIDINE HCL-50MG/ML(DEMEROL HCL) X6026 MEPERIDINE HCL-25MG/ML/DEMEROL HCL) X6030 ESTRADIOL IN OIL-5MG/ML X6036 METHYLPREDNISOLONE ACETATE-80MG/ML X6038 METHYLPREDNISOLONE ACETATE-40MG/ML

Code Description X6040 METHYLPREDNISOLONE ACETATE-20MG/ML (DEPO X6042 DEPO-MEDROL 20MG/CC - 5CC VIAL X6046 MEDROXYPROGES 400MG/ML 10ML VIAL PER ML X6048 MEDROXYPROGES 400MG/ML 2.5ML VIAL PER ML X6051 DEPO-PROVERA C 150MGM X6058 DEXAMETHASONE ACETATE-8MG/MLSUSP X6060 DEXPANTHENOL-250MG/ML (ILOPAN) X6062 DIHYDROERGOTAMINE MESYLATE-1MG/ML (DHE 45 X6064 DIAZEPAM-5MG/ML (VALIUM) X6070 DIAZOXIDE-300MG/20ML (HYPERSTAT I V) X6080 DIGOXIN-0.25MG/ML (DIGOXIN-LANOXIN) X6082 DIGOXIN-0.1MG/ML (LANOXIN) X6084 PHENYTOIN SOD PNT-50MG/ML (DILANTIN) X6086 HYDROMOPHONE HCL-4MG/ML( HYDROMOPHONE DIL X6090 HYDROMOPHONE HCL-2MG/ML/HYDROMOPHONE DIL X6092 HYDROMORPHONE HCL-1MG/ML/HYDROMORPHONE X6106 DISODIUM EDETATE 150MG/CC-20CC AMP X6108 DOBUTAMINE-250MG (AS HCL)DOBUTREX) X6110 METHADONE HCL-10MG/ML (DOLOPHINE HCL) X6114 DOXAPRAM HCL-20MG/ML(DOPRAM) X6116 DOXYCYCLINE-200MG (AS HYCLATE)/VIAL X6118 MINOCYCLINE HCL-100MG/VIAL (MINOCIN I V) X6122 DOXYCYCLINE-100MG (AS HYCLATE)VIAL X6126 DROPERIDOL-2.5MG/ML (INAPSINE) X6136 PENICILLIN G PROCAINE AQUEOUS 600000UNIT X6140 ETIDOCAINE HCL-1% (DURANEST) X6146 EDROPHONIUM CHLORIDE-10MG/ML(TENSILON) X6158 EPHEDRINE SUL-50MG/ML/1ML AMPS X6162 EPHEDRINE SUL-50MG/ML X6164 EPINEPHRINE HCL-0.1MG/ML X6166 EPINEPHRINE PNT-1:200 SUSP(SUS-PHRINE) X6168 ERGONOVINE MALEATE-0.2MG/ML(ERGOTRATE


TBSP10616-E (2/20)

Code Description X6174 ERYTHROMYCIN I.V.-1GM X6178 ERYTHROMYCIN I.V.-500MG X6196 ESTONE AQUEOUS SOL-5MG/ML (THEELINE X6204 ETHACRYNIC ACID-500MG (SOD EDECRIN) X6206 FENTANYL-0.05MG/ML (SUBLIMAZE) X6208 FENTANYL CITRATE/DROPERIDOL-0.05MG/2.5MG X6216 ORPHENADRINE CITRATE-30MG/ML(FMNNT-FX-O) X6220 FLUPHENAZINE ENAN&DECAN-25MG/ML X6222 FLUPHENAZINE HCL-2.5MG/ML (PROLIXIN) X6226 FOLIC ACIDS-5MG/ML (FOLVITE) X6228 FUROSEMIDE-10MG/ML (LASIX) X6236 PROMETHAZINE HCL/50 MG/ML (GANPHEN/K-PHEN X6240 GENTAMICIN SULFATE-40MG/ML (GARAMYCIN) X6242 GENTAMICIN SULFATE-10MG/ML (GARAMYCIN X6254 GLUCAGON-1MG/ML X6258 GLYCOPYPROLATE-0.2 MG/ML (ROBINUL) X6262 GOLD SOD THIOMALATE-50MG/ML(MYOCHRYSINE) X6274 HALOPERIDOL-5MG/ML (HALDOL) X6282 HEPARIN LOCK FLUSH SOL-100UNITS/ML X6284 HEPARIN LOCK FLUSH SOL-10UNITS/ML X6286 HEPARIN SOD INJ(USP)40,000UNITS/ML X6288 HEPARIN SOD INJ-20,000UNITS/ML(HEPARIN) X6296 HEPARIN SOD INJ(USP)10,000UNIT/ML X6298 HEPARIN SOD INJ(USP)7500UNITS/ML(HEP/SOD X6302 HEPARIN SOD INJ(USP)5000UNITS/ML X6304 HEPARIN SOD INJ(USP)5000UNITS/0.5ML X6306 HEPARIN SOD INJ(USP)2500UNITS/ML (HEP/SOD X6308 HEPARIN SOD INJ(USP)1000UNITS/ML (HEPARIN X6320 HEXADROL PHOSPHATE-10MG/ML X6326 TESTOSTERONE-100MG/ML X6332 HYDROCORTISONE-25MG/ML X6334 HYDROCORTONE PHOSPHATE-50MG/ML

Code Description X6336 HYDROXYZINE-50MG/ML (VISTARIL) X6354 PROPRANOLOL HCL-1MG/ML (INDERAL) X6366 INSULIN INJ/BEEF/PORK/PANCREAS-100UNITML X6408 ISOPROTERENOL HCL-1:5000 SOL/1ML (IPRENOL X6410 ISONIAZID(INH)10MG/ML (NYDRAZIO) X6422 KANAMYCIN SULFATE-500MG/2ML VIAL (KANTREX X6424 KANAMYCIN SULFATE-75MG/2ML VIAL(KANTREX) X6426 KANAMYCIN SULFATE-1GM/3ML VIAL(KANTREX) X6432 KENALOG-10 X6434 KETAMINE-100ML/ML (KETATECT KETALAR) X6436 KETAMINE-50MG/ML (KETATECT KETALAR) X6438 KETAMINE-10MG/ML/KETATECT/KETALAR) X6440 PREDNISOLONE ACETATE-25MG/ML X6444 LIDOCAINE HCL-2% 1:100,000EPINEPHRINE X6452 LEVARTERENOL (NOREPINEPHRINE-1MG X6454 LEVORPHANOL TARTRATE-2MG/ML(LEVO-DROMORA X6456 LEVOLHYROXINE-500MCG/ML(L-T-S) NOROXINE X6462 LIDOCAINE HCL-20%(200MG/ML) X6464 LIDOCAINE HCL-10%(100MG/ML) X6466 LIDOCAINE HCL-5% 7.5%GLUCOSE( XYLOCAINE X6470 LIDOCAINE HCL-2%(20MG/ML) X6474 LIDOCAINE HCL-2% 1:200,000EPINEPHRINE X6476 LIDOCAINE HCL-2% 1:50000EPINEPHRINE X6478 LIDOCAINE HCL-1.5% (XYLOCAINE HCL) X6480 LIDOCAINE HCL-1.5% 7.5%DEXTROSE XYLOCAIN X6482 LIDOCAINE HCL-1.5% 1:200,000EPINEPHRINE X6486 LIDOCAINE HCL-1% 1:200,000EPINEPHRINE X6488 LIDOCAINE HCL-1% 1:100,000EPINEPHRINE X6490 LIDOCAINE HCL-0.5% (XYLOCAINE HCL) X6492 LIDOCAINE HCL-0.5% 1:200,000 EPINEPHRINE X6494 LIDOCAINE HCL-4% (40MG/ML) X6496 LIDOCAIN HCL-1% (10MG/ML(LIDOCAIN HCL


TBSP10616-E (2/20)

Code Description X6504 LINCOMYCIN-300MG/ML/2ML U-JECT(LINCOCIN) X6506 PHENOBARBITAL SOD-130MG/ML (LUMINOL SOD) X6512 MAGNESIUM SULFATE-50% X6514 MAGNESIUM SULFATE-12.5% X6516 MAGNESIUM SULFATE-10% X6520 MANNITOL 25% AMPULE X6522 MANNITOL-20% (OSMITROL) X6524 MANNITROL-15% (OSMITROL) X6526 MANNITOL-10% (OSMITROL) X6528 MANNITOL-5% (OSMITROL) X6530 BUPIVACAINE HCL-0.5% (MARCAINE) X6550 MEPHENTERMINE SUL-30MG/ML (WYAMINE SUL) X6552 MEPHENTERMINE SUL-15MG/ML (WYAMINE SUL) X6556 MESORIDAZINE-25MG/ML (SERENTIL) X6560 METHOCARBAMOL-100MG/ML (ROBAXIN) X6562 METHOXAMINE HCL20MG/ML/1ML AMPS (VASOXYL X6566 METHYLERGONOVINE MALEATE-0.2MG/ML X6580 METHYLPREDNISOLONE SOD SUCCINATE62.5MGML X6582 METOCURINE OXIDE-2MG/ML (METUBINE LODIDE X6592 MORPHINE-15MG/ML (MORPHINE SULFATE) X6594 MORPHINE-10MG/ML (MORPHINE SULFATE) X6596 MORPHINE-8MG/ML (MORPHINE SULFATE) X6598 M.V.I-10 ML X6600 M.V.I CONCENTRATE-5ML X6604 NAFCILLIN SOD-2G VIAL (NAFCIL,UNIPEN) X6606 NAFCILLIN SOD-1G VIAL( NAFCIL-UNIPEN) X6610 NAFCILLIN SOD-500MG VIAL (NAFCILLIN X6612 NALBUPHINE HCL-10MG/ML/NUBAIN) X6614 NALOXONE HCL-0.4MG/ML (NARCAN) X6616 NALOXONE HCL-0.02MG/ML (NARCAN) X6618 THIOTHIXENE-2MG/ML (NAVANE) X6620 TOBRAMYCIN SULFATE-40MG/ML (NEBCI

Code Description X6622 TOBRAMYCIN SULFATE-10MG/ML2ML VIAL X6624 PENTOBARBITAL SOD-50MG/ML (NEMBUTAL SOD) X6626 PHENYLCPHRINE HCL-1%1ML AMPS (NEO-SYNEPHR X6630 NEOSTIGMINE METHYLSULFATE-1:4000 SOL/1ML X6632 NEOSTINGMINE METHYLSULFATE-1:2000 SOL X6634 NEOSTIGMINE METHYLSULFATE-1:1000 SOL X6636 NITROPRUSSIDE SOD-50MG/5ML (NIPRIDE) X6638 PROMAZINE HCL-50MG/ML (NORAZINE HCL) X6640 PROCAINE HCL-10% (NOVOCAIN) X6642 PROCAINE HCL-2%( NOVOCAIN) X6644 PROCAINE HCL-1% (NOVOCAIN) X6646 OXYMORPHONE HCL-1.5MG/ML/NUMORPHAN/ X6648 OXYMORPHONE HCL-1MG/ML (NUMORPHAN) X6658 OXYTETRACYOLINE 125MG/CC IM (2CC AMPS) X6660 OXYTETRACYCLINE 50MG/CC IM (TERRAMYCIN) X6664 OXYTETRACYCLINE 250MG/VIAL IV (TERRMYCIN X6666 OXYTOCIN-10 UNITS/ML(PITOCIN/SYNTOCINON X6670 PANCURONIUM BROMIDE-2MG/ML (PAVULON) X6672 PANCURONIUM BROMIDE-1MG/ML (PAVULON) X6700 PENICILLIN G POTASSIUM-20,000,000 UNITS X6702 PENICILLIN G POTASSIUM-10,000,000 UNITS X6704 PENICILLIN G POTASSIUM-5,000,000 UNITS X6706 PENICILLIN G POTASSIUM-1,000,000 UNITS X6714 PENICILLIN G PROCAINE AQUEOUS 2,400,000 X6716 PENICILLIN G PROCAINE AQUEOUS 1,2000,000 X6718 PENTAMIDINE-150MG X6720 PENTAZOCINE-30MG/ML (TALWIN) X6728 THIOPENTAL SOD-10G (PENTOTHAL) X6730 THIOPENTAL SOD-5G (PENTOTHAL) X6732 THIOPENTAL SOD-1G (PENTOTHAL) X6734 THIOPENTAL SOD-500MG (PENTOTHAL) X6736 THIOPENTAL SOD-400MG (PENTOTHAL)


TBSP10616-E (2/20)

Code Description X6738 THIOPENTAL SOD-250 MG (PENTOTHAL) X6740 PERPHENAZINE-5MG/ML (TRILAFON) X6742 PROMETHAZINE HCL/25 MG/ML (PHENAZINE) X6754 PHENOBARBITOL SOD-65MG/ML X6758 PHENTOLAMINE-5MG (REGITINE) X6760 VASOPRESSIN-20PRESSOR UNITS(PITRESSIN) X6776 POLYMYXIN B SULFATE-500,000 UNITS X6778 TETRACAINE HCL-1% (PONTOCAINE) X6780 TETRACAINE HCL-0.3% 6%DEXTROSE (PONTOCAIN X6782 TETRACAINE HCL-0.2% 6%DEXTROSE (PONTOCAIN X6784 PRALIDOXIME CHLORIDE-1G-EMERGENCY KIT X6792 PROCAINAMDIDE HCL-500MG/ML (PRONESTYL) X6794 PROCAINAMIDE HCL-100MG/ML (PRONESTYL) X6810 PROGESTERONE (IN OIL) 50MG/CC X6816 PROTAMINE SULFATE-10MG/ML X6826 PYRIDOSTIGMINE BROMIDE-5MG/ML(MESTINON X6828 SUCCINYLCHOLINE CHLORIDE-100MG/ML(Q.S.) X6830 SUCCIMYLCHOLINE CHLORIDE-50MG/ML(Q.S.) X6832 QUINIDINE GLUCONATE/80MG/ML X6856 SCOPOLAMINE HBR-1.0 MG/ML X6862 SCOPOLAMINE HBR-0.4 MG/ML X6870 SECOBARBITAL SOD-50MG/ML (SECONAL SOD) X6888 SOLU-CORTEF-1000MG/8ML/VIAL X6890 SOLU-CORTEF-500MG/4ML/VIAL X6892 SOLU-CORTEF-250MG/2ML/VIAL X6894 SOLU-CORTEF-100MG/ML/VIAL X6896 SPECTINOMYCIN-400MG (AS HCI)ML/2G VIAL X6912 TRIFLUOPERAZINE-2MG/ML (STELAZINE) X6944 TESTOSTERONE PROPIONATE-100MG/ML X6972 TICARCILLIN DISODIUM-3G PWD VIAL(TICAR) X6974 TICARCILLIN DISODIUM-1G PWD VIALS(TICAR) X6976 TRIACINOLONE DIACETATE-25MG/ML SUSP

Code Description X6978 TRIFLUPROMZINE HCL-20MG/ML (VESPIRIN) X6980 TRIFLUPROMAZINE HCL-10MG/ML (VESPIRIN) X6984 TUBOCURARINE CHLORIDE-3MG/ML X6996 UREA-40GM/150M L(UREAPHIL) X6998 VANCOMYCIN-500MG(AS HCL)/10ML(VANCOCIN) X7010 HYDROXYZINE-25MG/ML (VISTARIL) X7025 CEFOTAXIME SODIUM 0.5 GM X7026 CEFOTAXIME SODIUM 1 GM X7027 CEFOTAXIME SODIUM 2 GM X7034 SOMATREM (PROTROPIN) 1MG X7036 SOMATROPIN (HUMATROPE) 1MG X7038 CEREDASE, SEVERE GAUCHERS DISEASE X7050 ONDANSETRON HCL - 1 MG X7052 PACLITAXEL 30 MGM X7060 ZOLADEX (GOSERELIN ACETATE) X7061 ZOLADEX 10.8 MG DEPOT X7104 GRANISETRON IMG 1ML X7105 GRANISETRON ORAL TABLETS-1MG X7108 BACLOFEN INJECTION 10MG X7122 CATHFLO ACTIVASE 2MG INJECTION X7364 SARGRAMOSTIM 250 UG/VIAL X7366 SARGRAMOSTIM 500 UG/VIAL X7420 GANCICLOVIR INTRAVITREAL IMPLANT X7422 LUPRON DEPOT 3.75MG X7424 LUPRON DEPOT 7.50 MG X7426 LUPRON DEPOT 22.50 MG X7428 LUPRON DEPOT-PED 7.50 MG X7430 LUPRON DEPOT-PED 11.25 MG X7432 LUPRON DEPOT PED 15.00 MG. X7434 CIDOFOVIR 375MG X7436 UROKINASE FOR CATH CLEARANCE-5000 UNITS X7444 PAMIDRONATE 30MG


TBSP10616-E (2/20)

Code Description X7446 LUPRON DEPOT 3-MONTH 11.25MG X7448 LUPRON DEPOT-4 MONTH 30.0MG X7452 NUTROPIN 1MG X7454 NUTROPIN AQ 1MG X7456 PENICILLIN G BENZATHINE 600,000 UNITS X7458 PENICILLIN G BENZATHINE 1,200,000 UNITS X7460 PENICILLIN G BENZATHINE, PARENTERAL 1,200 X7462 PENICILLIN G BENZATHINE, PARENTERAL 2,400 X7464 THYROGEN 1.1 MG X7470 FOMIVIRSEN 0.25 ML VIAL X7478 DOLASETRON 10MG X7479 DOLASETRON 12.5MG X7480 INFLIXIMAB 100MG X7488 CLONIDINE HYCROCHLORIDE 1 MG X7490 LUNELLE 5-25MG/0.5ML X7492 VENOFER 100MG INTRAVENOUS INJECTION X7494 SOMATROPIN 1MG INJECTION X7496 FERRLECIT 62.5MG INJECTION X7498 ZIPRASIDONE 20MG INJECTION X7500 DOXORUBICIN HCL-50MGVIAL 250MG LACTOSE X7502 DOXORUBICIN HCL-10MG/VIAL 50MG LACTOSE X7504 ASPARAGINASE-10,000IU/10ML VIAL(ELSPAR) X7506 CARMUSTINE(BCNU)100MG/VIAL (BICNU) X7508 BLEOMYCIN SUL-15 UNITS/AMP (BLENOXANE) X7510 CALCITRIOL 1MCG/ML - CALCIJEX X7512 CALCITRIOL 2MCG/ML - CALCIJEX X7514 CERUBIDINE 20MG VIAL X7518 CISPLATIN 50MG VIAL X7520 DACTINOMYCIN (ACTINOMYCIN D)0.5MG/3MLVIAL X7522 CYCLOPHOSPHAMIDE-500MG30ML VIAL(CYTOXAN) X7524 CYCLOPHOSPHAMIDE-200MG/20ML VIAL(CYTOXIN X7526 CYCLOPHOSPHAMIDE-100MG/10VIAL(CYTOXAN)

Code Description X7528 CYTARABINE(ARA-C)500MG VIALS (CYTOSAR) X7530 CYTABABINE (CYTOSINE ARAB, ARA-C)100MGVIAL X7532 DACCABAZINE (DTIC-200MG/20ML VIAL(DTIC X7536 DIETHYLSTILBESTEROL DIPH-0.25GM ASS/5ML X7542 ETOPOSIDE (VEPESID) 20MGM/ML X7544 FLOXURIDINE-500MG/5ML VIAL(FUDR) X7546 FLUOROURACIL-500MG/10ML AMPULE X7548 INTERFERON ALFA-2A X7550 INTERFERON ALFA-2B X7551 INTERFERON ALFA - N3 X7552 MECHLORETHAMINE HCL-10MG/20ML TRIT 100MG X7556 METHOTREXATE-20MG (AS SOD)VIAL FOR RECONS X7558 METHOTREXATE-25MG (AS SOD/ML/2ML VIAL X7562 METHOTREXATE 100 MG VIAL X7564 MITHRAMYCIN-2.5/VIAL 100MG MANNITOL X7566 MITOMYCIN-20MG/VIAL (MUTAMYCIN) X7568 MITOMYCIN-5MG/VIAL (MUTAMYCIN) X7572 VINCRISTINE SUL (VCR-1MG 10MG/ACTOSE VIAL X7574 STREPTOZOCIN 1VIAL /ZANOSAR X7576 TRIETHYLENETHIOPHOSPHORAMIDE-15MG/VIAL X7578 VINBLASTINE SUL(VLB)10MG/10ML VIAL X7580 VINORELBINE 1OMG 1ML X7584 IFOSFAMIDE 100MG X7586 MESNA 100MG X7632 INTERLEUKIN-2 22MILLION IU X7638 DOCETAXEL 20 MG X7640 TRASTUZUMAB 10MG X7642 AMIFOSITINE 500 MG INJECTION X7644 FLUDARABINE 50 MG INJECTION X7646 EPIRUBICIN 50MG/25ML X7648 TRIPTORELIN 3.75 MG (TRELSTAR) X7650 ZOLEDRONATE 4 MG INTRAVENOUS INJECTION


TBSP10616-E (2/20)

Code Description X7652 PEGFILGRASTIM 6 MG X7654 FULVESTRANT 250 MG INJECTION X7706 ORAL CONTRACEPIVE MEDICATIONS X7716 ZITHROMAX, 250 MGM X7718 AZITHROMYCIN FOR ORAL SUSP, 1000 MG X7720 PREVEN EMERGENCY CONTRACEPTIVE KIT X7722 PLAN B EMERGENCY CONTRACEPTIVE X7724 MIFEPRISTONE 200MG X7726 MISOPROSTOL 200MG X7728 ETHINYL ESTRADIOL/NORELGEST X7730 ETONOGESTREL/ETHINYL ESTRADIOL 90281 HUMAN IG IM 90283 HUMAN IG IV 90284 HUMAN IG SC 90378 SUBACUTE CARE, INITIAL, NEW PAT INTERMED X 90379 RSV IG, IV 90384 RH IG FULL-DOSE IM 90385 RH IG MINIDOSE IM 90386 RH IG IV 90399 IMMUNE GLOBULIN

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