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NDC | HCPCS | HCPCS Description | NDC Label | Route of Administration |
|---|---|---|---|---|
63459-0104-50 | Q5115 | INJECTION, RITUXIMAB-ABBS, BIOSIMILAR, (TRUXIMA), 10 MG | TRUXIMA (SDV,PF) 10 MG/1 ML | IV |
63459-0177-14 | J9262 | INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG | SYNRIBO (PF,LYOPHILIZED) 3.5MG | SC |
63459-0391-20 | J3490 | UNCLASSIFIED DRUGS | TREANDA | IV |
63459-0600-10 | J9017 | INJECTION, ARSENIC TRIOXIDE, 1 MG | TRISENOX (10X10 AMP,PF) 1 MG/ML | IV |
63459-0601-06 | J9017 | INJECTION, ARSENIC TRIOXIDE, 1 MG | TRISENOX (PF) 2 MG/1 ML | IV |
63459-0918-59 | J1447 | INJECTION, TBO-FILGRASTIM, 1 MICROGRAM | GRANIX (PF) 300 MCG/1 ML | SC |
63459-0920-59 | J1447 | INJECTION, TBO-FILGRASTIM, 1 MICROGRAM | GRANIX (PF) 480 MCG/1.6 ML | SC |
63481-0367-06 | J3030 | INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) | SUMAVEL DOSEPRO 6 MG/0.5 ML | SC |
63481-0624-10 | J2410 | INJECTION, OXYMORPHONE HCL, UP TO 1 MG | OPANA (1MLX10,PARABEN-FREE) 1 MG/ML | IJ |
63629-1262-01 | J8999 | PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS | AROMASIN 25 MG | PO |
63629-1335-01 | Q0164 | PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PROCHLORPERAZINE MALEATE 10 MG | PO |
63629-1335-02 | Q0164 | PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PROCHLORPERAZINE MALEATE 10 MG | PO |
HCPCS Code | Description | Billing Unit | SA Type |
|---|---|---|---|
B4103 | Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids) | 500 ml = 1 unit | N |
B4104 | Additive for enteral formula | I.C. | N |
B4105 | In-line cartridge containing digestive enzyme(s) for enteral feeding, each (Reviewed on a case by case basis, documentation must include least costly options tried and why they failed) Physician or OCMO review required | each | Y |
B4149 | Enteral formula, manufactured blenderized natural foods with intact nutricients, includes protients, fats, carbohydrates, vitamins and minerals, may include fiber
This code is for EPSDT use only. | 100 Calories = 1 Unit | N |
B4150 | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber | 100 Calories= 1 Unit | N |
B4152 | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber | 100 Calories= 1 Unit | N |
B4153 | Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber | 100 Calories= 1 Unit | N |
B4154 | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber | 100 Calories= 1 Unit | N |
B4155 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination | 100 Calories= 1 Unit | N |
B4157 | Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber | Per can | N |
B4158 | Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron | Per can | N |
B4159 | Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron | Per can | N |
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