Code |
Description |
Effective "from" date of service |
Effective "through" date of service |
---|---|---|---|
J0209 |
Injection, sodium thiosulfate (hope), 100 mg |
4/1/2024 |
Present |
J0211 |
Injection, sodium nitrite 3 mg and sodium thiosulfate 125 mg (nithiodote) |
7/1/2024 |
Present |
J0220 |
Injection, alglucosidase alfa, 10 mg, not otherwise specified |
1/1/2024 |
Present |
J0380 |
Injection, metaraminol bitartrate, per 10 mg |
1/1/2024 |
Present |
J0390 |
Injection, chloroquine HCl, up to 250 mg |
1/1/2024 |
Present |
J0400 |
Injection, aripiprazole, intramuscular, 0.25 mg |
1/1/2024 |
Present |
J0571 |
Buprenorphine, oral, 1 mg |
1/1/2024 |
Present |
J0572 |
Buprenorphine/naloxone, oral, less than or equal to 3 mg buprenorphine |
1/1/2024 |
Present |
J0573 |
Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg buprenorphine |
1/1/2024 |
Present |
J0574 |
Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg buprenorphine |
1/1/2024 |
Present |
J0575 |
Buprenorphine/naloxone, oral, greater than 10 mg buprenorphine |
1/1/2024 |
Present |
J0600 |
Edtate calcium disodium, up to 1000 mg |
1/1/2024 |
Present |
J0620 |
Injection, calcium glycerophosphate and calcium lactate, per 10 ml |
1/1/2024 |
Present |
J0650 |
Injection, levothyroxine sodium, not otherwise specified, 10 mcg |
4/1/2024 |
Present |
J0716 |
Injection, Centruroides immune f(ab)2, up to 120 mg |
1/1/2024 |
Present |
J1180 |
Injection, dyphylline, up to 500 mg |
1/1/2024 |
Present |
J1434 |
Injection, fosaprepitant (focinvez), 1 mg |
4/1/2024 |
Present |
J1436 |
Injection, etidronate disodium, per 300 mg |
1/1/2024 |
Present |
J1562 |
Injection, immune globulin (Vivaglobin), 100 mg |
1/1/2024 |
Present |
J1598 |
Injection, glycopyrrolate (fresenius kabi), not therapeutically equivalent to J1596, 0.1 mg |
7/1/2024 |
9/30/2024 |
J1599 |
Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg |
1/1/2024 |
Present |
J1600 |
Injection, gold sodium thiomalate, up to 50 mg |
1/1/2024 |
Present |
J1675 |
Injection, histrelin acetate, 10 mcg |
1/1/2024 |
Present |
J1710 |
Injection, hydrocortisone sodium phosphate, up to 50 mg |
1/1/2024 |
Present |
J1729 |
Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg |
1/1/2024 |
Present |
J1749 |
Injection, iloprost, 0.1 mcg |
10/1/2024 |
Present |
J1810 |
Injection, droperidol and fentanyl citrate, up to 2 ml ampule |
1/1/2024 |
Present |
J1840 |
Injection, kanamycin sulfate, up to 500 mg |
1/1/2024 |
Present |
J1850 |
Injection, kanamycin sulfate, up to 75 mg |
1/1/2024 |
Present |
J1890 |
Injection, cephalothin sodium, up to 1 g |
1/1/2024 |
Present |
J1990 |
Injection, chlordiazepoxide HCl, up to 100 mg |
1/1/2024 |
Present |
J2003 |
Injection, lidocaine hydrochloride, 1 mg |
10/1/2024 |
Present |
J2004 |
Injection, lidocaine hcl with epinephrine, 1 mg |
10/1/2024 |
Present |
J2180 |
Injection, meperidine and promethazine HCl, up to 50 mg |
1/1/2024 |
Present |
J2252 |
Injection, midazolam in 0.8% sodium chloride, intravenous, not therapeutically equivalent to j2250, 1 mg |
10/1/2024 |
Present |
J2253 |
Injection, midazolam (seizalam), 1 mg |
10/1/2024 |
Present |
J2355 |
Injection, oprelvekin, 5 mg |
1/1/2024 |
Present |
J2400 |
Injection, chloroprocaine HCl, per 30 ml |
1/1/2024 |
Present |
J2410 |
Injection, oxymorphone HCl, up to 1 mg |
1/1/2024 |
Present |
J2468 |
Injection, palonosetron hydrochloride (avyxa), not therapeutically equivalent to J2469, 25 micrograms |
7/1/2024 |
Present |
J2504 |
Injection, pegademase bovine, 25 IU |
1/1/2024 |
Present |
J2513 |
Injection, pentastarch, 10% solution, 100 ml |
1/1/2024 |
Present |
J2650 |
Injection, prednisolone acetate, up to 1 ml |
1/1/2024 |
Present |
J2670 |
Injection, tolazoline HCl, up to 25 mg |
1/1/2024 |
Present |
J2725 |
Injection, protirelin, per 250 mcg |
1/1/2024 |
Present |
J2730 |
Injection, pralidoxime chloride, up to 1 g |
1/1/2024 |
Present |
J2770 |
Injection quinupristin/dalfopristin 500mg/(150/3520) |
1/1/2024 |
Present |
J2780 |
Injection, ranitidine HCl, 25 mg |
1/1/2024 |
Present |
J2797 |
Injection, rolapitant, 0.5 mg |
1/1/2024 |
Present |
J2810 |
Injection, theophylline, per 40 mg |
1/1/2024 |
Present |
J2993 |
Injection, reteplase, 18.1 mg |
1/1/2024 |
Present |
J3265 |
Injection, torsemide, 10 mg/ml |
1/1/2024 |
Present |
J3302 |
Injection, triamcinolone diacetate, per 5 mg |
1/1/2024 |
Present |
J3303 |
Injection, triamcinolone hexacetonide, per 5 mg |
1/1/2024 |
Present |
J3310 |
Injection, perphenazine, up to 5 mg |
1/1/2024 |
Present |
J3316 |
Injection, triptorelin, extended-release, 3.75 mg |
1/1/2024 |
Present |
J3350 |
injection, urea, up to 40 g |
1/1/2024 |
Present |
J3355 |
Injection, urofollitropin, 75 IU |
1/1/2024 |
Present |
J3400 |
Injection, triflupromazine HCl, up to 20 mg |
1/1/2024 |
Present |
J3472 |
Injection, hyaluronidase, ovine, preservative free, per 1,000 USP units |
1/1/2024 |
Present |
J7110 |
Infusion, dextran 75, 500 ml |
1/1/2024 |
Present |
J7131 |
Hypertonic saline solution, 1 ml |
1/1/2024 |
Present |
J7191 |
Factor VIII (antihemophilic factor (porcine)), per IU |
1/1/2024 |
Present |
J7196 |
Injection, antithrombin recombinant, 50 IU |
1/1/2024 |
Present |
J7310 |
Ganciclovir, 4.5 mg, long-acting implant |
1/1/2024 |
Present |
J7315 |
Mitomycin, ophthalmic, 0.2 mg |
1/1/2024 |
Present |
J7330 |
Autologous cultured chondrocytes, implant |
1/1/2024 |
Present |
J7352 |
Afamelanotide implant, 1 mg |
1/1/2024 |
Present |
J9020 |
Injection, asparaginase, not otherwise specified, 10,000 units |
1/1/2024 |
Present |
J9051 |
Injection, bortezomib (Maia), not therapeutically equivalent to j9041, 0.1 mg |
1/1/2024 |
Present |
J9072 |
Injection, cyclophosphamide, (Dr. Reddy's), 5 mg |
1/1/2024 |
6/30/2024 |
J9074 |
Injection, cyclophosphamide (Sandoz), 5 mg |
4/1/2024 |
6/30/2024 |
J9098 |
Injection, cytarabine liposome, 10 mg |
1/1/2024 |
Present |
J9151 |
Injection, daunorubicin citrate, liposomal formulation, 10 mg |
1/1/2024 |
Present |
J9198 |
Injection, gemcitabine hydrochloride, (infugem), 100 mg |
4/1/2024 |
Present |
J9213 |
Injection, interferon, alfa-2a, recombinant, 3 million units |
1/1/2024 |
Present |
J9214 |
Injection, interferon, alfa-2b, recombinant, 1 million units |
10/1/2023 |
Present |
J9219 |
Leuprolide acetate implant, 65 mg |
1/1/2024 |
Present |
J9225 |
Histrelin implant (Vantas), 50 mg |
1/1/2024 |
Present |
J9247 |
Injection, melphalan flufenamide, 1 mg |
1/1/2024 |
Present |
J9249 |
Injection, melphalan (apotex), 1 mg |
4/1/2024 |
Present |
J9255 |
Injection, methotrexate (accord) not therapeutically equivalent to j9250 and j9260, 50 mg |
1/1/2024 |
Present |
J9258 |
Injection, paclitaxel protein-bound particles (teva) not therapeutically equivalent to j9264, 1 mg |
1/1/2024 |
7/1/2024 |
J9322 |
Injection, permetrexed (Bluepoint) not therapeutically equivalent to J9305, 10 mg |
1/1/2024 |
Present |
J9324 |
Injection, pemetrexed (pemrydi rtu), 10 mg |
1/1/2024 |
2/29/2024 |
J9361 |
Injection, efbemalenograstim alfa-vuxw, 0.5 mg |
7/1/2024 |
Present |
J9393 |
Injection, fulvestrant (teva) not therapeutically equivalent to j9395, 25 mg |
1/1/2024 |
Present |
Q5133 |
Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mg |
4/1/2024 |
4/30/2024 |
Q5134 |
Injection, natalizumab-sztn (tyruko), biosimilar, 1 mg |
4/1/2024 |
Present |
Q5136 |
Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg |
10/1/2023 |
Present |
Q5137 |
Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg |
7/1/2024 |
Present |
Q5138 |
Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg |
7/1/2024 |
Present |