NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only

Transcription

1 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN ZEVALIN Y-90 VIAL 9/1/ /31/ A9581 INJECTION, GADOXETATE DISODIUM, 1 ML EOVIST 2.5 MMOL/10 ML VIAL 10/1/ /99/ J0171 ADRENALIN EPINEPHRINE INJECT EPINEPHRINE 0.1 MG/ML SYRINGE 1/1/ /99/ J0171 ADRENALIN EPINEPHRINE INJECT ADRENALIN CL 1 MG/ML VIAL 1/1/ /99/ J0171 ADRENALIN EPINEPHRINE INJECT EPIPEN 2-PAK 0.3 MG AUTO-INJCT 1/1/ /99/ J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/ /99/ J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/ /99/ J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 3/1/ /99/ J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/ J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 3/1/2010 9/30/ J0221 LUMIZYME INJECTION LUMIZYME 50 MG VIAL 1/1/ /99/ J0257 GLASSIA INJECTION GLASSIA 1 GM/50 ML VIAL 1/1/ /99/ J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 1 MG/ML VIAL 3/1/ /99/ J0490 BELIMUMAB INJECTION BENLYSTA 120 MG VIAL 1/1/ /99/9999 Y J0490 BELIMUMAB INJECTION BENLYSTA 400 MG VIAL 1/1/ /99/9999 Y J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 600,000 UNIT/ML 1/1/ /99/ J0561 PENICILLIN G BENZATHINE INJ PEN G 1.2 MILLION UNIT/2 ML 1/1/ /99/ J0561 PENICILLIN G BENZATHINE INJ BICILLIN L-A 1,200,000 UNITS 1/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 300 UNIT VIAL 4/1/2012 3/31/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 500 UNITS VIAL 4/1/2012 3/31/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 100 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/ /31/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 4/1/ /99/ J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 200 UNITS VIAL 4/1/ /99/ J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 500 UNITS VIAL 4/1/ /99/ J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 300 UNIT VIAL 4/1/ /99/ J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 2,500 UNIT/0.5 ML VIAL 2/1/ /99/ J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 5,000 UNITS/1 ML VIAL 2/1/ /99/ J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 10,000 UNITS/2 ML VIAL 2/1/ /99/ J0588 INCOBOTULINUMTOXIN A XEOMIN 50 UNITS VIAL 1/1/ /99/ J0588 INCOBOTULINUMTOXIN A XEOMIN 100 UNITS VIAL 1/1/ /99/ J0598 C-1 ESTERASE, CINRYZE BERINERT 500 UNIT KIT 2/1/ /99/ J0638 CANAKINUMAB INJECTION ILARIS 180 MG VIAL 1/1/ /99/9999

2 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 2/15/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 2/15/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 50 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 3/1/2008 8/31/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 3/1/2008 4/30/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 3/1/2008 5/31/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 3/1/2008 6/30/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 500 MG VL 3/1/ /99/ J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 8/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 12/30/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/2/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 11/9/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 11/9/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 11/9/2009 5/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 5/29/2008 1/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/2008 4/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 5/29/2008 1/31/2013

3 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 5/29/2008 1/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 5/29/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 5/29/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 1/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/2/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/2/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 5/29/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 2 GM VIAL 3/1/2008 8/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 10 GM VIAL 3/1/2008 8/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM-D5W BAG 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM-D5W BAG 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 7/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/2013

4 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/2008 9/30/2011

5 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 3/1/2008 9/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 2/28/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 3/1/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 3/1/2008 8/31/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 3/1/2008 6/30/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 7/17/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 12/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/30/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 8/16/ /99/ J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 250 MG VIAL 3/1/2008 9/30/ J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 400 MG VIAL 1/1/ /99/ J0712 CEFTAROLINE FOSAMIL INJ TEFLARO 600 MG VIAL 1/1/ /99/ J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG CORTROSYN 0.25 MG VIAL 1/1/ /99/ J0840 CROTALIDAE POLY IMMUNE FAB CROFAB VIAL 1/1/2012 6/30/ J0886 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 5/1/ /99/ J0897 DENOSUMAB INJECTION XGEVA 120 MG/1.7 ML VIAL 1/1/ /99/ J0897 DENOSUMAB INJECTION PROLIA 60 MG/ML SYRINGE 1/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 8/4/ /99/9999

6 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 METHYLPREDNISOLONE 80 MG/ML VL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 40 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 8 DEPO-MEDROL 80 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/2/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/16/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/16/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/30/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 8/30/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/30/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 2/28/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/2008 3/31/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 3/1/ /99/ J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE INTENSOL 1MG/1ML 3/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML VL 11/10/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 50 MG/5 ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 500 MG/50 ML VIA 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/ /99/9999

7 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 250 MG VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 6/1/2009 3/1/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML VIAL 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 1 MG/ML SYRINGE 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 4 MG/ML SYRIN 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML SYRINGE 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 7/1/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 6/1/2009 9/30/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 4 MG/ML AMP 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 1 MG/ML AMP 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 2 MG/ML AMP 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 8/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 9/30/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 6/1/2009 6/30/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 6/1/2009 3/31/ J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 6/1/ /99/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/ /99/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/ /99/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 9/30/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 3/1/2008 7/1/ J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 3/1/ /99/ J1453 FOSAPREPITANT INJECTION EMEND 150 MG VIAL 11/15/ /99/9999

8 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1453 FOSAPREPITANT INJECTION EMEND 115 MG VIAL 11/1/2009 7/31/ J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/ /99/ J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/ /99/ J1557 GAMMAPLEX INJECTION GAMMAPLEX 5% VIAL 1/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN FLEBOGAMMA DIF 10% VIAL 2/8/ /99/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 G (IGA<1) SOLN 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 G (IGA<1) SOL 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 5 GM VIAL-DILUE 3/1/ /31/ J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 10 GM VIAL-DILU 3/1/ /31/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 0.5 GM VL W-ST 3/1/ /31/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 2.5 GM VL W/ST 3/1/2010 5/25/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 GM VL W/SET 3/1/2010 4/11/ J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 GM VL W/ST 3/1/2010 6/21/ J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 3 GM VIAL 3/1/2010 6/3/ J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 6 GM VIAL 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 12 GM VIAL 3/1/ /99/ J1566 INJECTION, IMMUNE GLOBULIN IVEEGAM EN 5 GM VIAL 3/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 2/8/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 10% VIAL 11/15/ /99/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA 5% VIAL 4/1/ /31/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1572 Flebogamma injection FLEBOGAMMA DIF 5% VIAL 4/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/2009 9/30/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/ /31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 1/1/ /99/9999

9 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 1/1/2010 8/31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 1/1/ /31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 6/1/2009 6/28/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 6/1/ /99/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 1 MG/ML VIAL 6/1/2009 7/31/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 4 MG/4 ML VIAL 6/1/ /30/ J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 0.1 MG/ML VIAL 6/1/2009 3/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 3/1/2008 3/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 100 AMPUL 3/1/2008 5/31/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/2008 9/30/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 3/1/ /99/ J1725 HYDROXYPROGESTERONE CAPROATE MAKENA 250 MG/ML VIAL 1/1/ /99/ J1725 HYDROXYPROGESTERONE CAPROATE PROGESTERONE OIL 50 MG/ML VL 1/1/ /99/ J1750 INJECTION, IRON DEXTRAN INFED 100 MG/2 ML VIAL 1/1/ /99/ J1750 INJECTION, IRON DEXTRAN VENOFER 100 MG/5 ML VIAL 1/1/ /99/ J1750 INJECTION, IRON DEXTRAN DEXFERRUM 100 MG/2 ML VIAL 1/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 5/15/2009 5/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML ISECURE SYR 3/1/2008 4/1/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2ML ISECURE 3/1/ /1/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/ /99/9999

10 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML CARPUJECT 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML ISECURE SYR 3/1/ /31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML CARPUJECT 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 9/30/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 7/1/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML SYRINGE 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML SYRINGE 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC IM 30 MG/ML SYRING 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/2008 5/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 8/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 300 MG/10 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 15 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 30 MG/ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/2008 3/31/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KETOROLAC 60 MG/2 ML VIAL 3/1/ /99/ J1885 KETOROLAC TROMETHAMINE, PER 15 MG KENALOG MG/ML VIAL 3/1/ /99/ J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT MG 3MO KIT 1/1/ /99/ J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 22.5 MG 3MO KIT 1/1/ /99/ J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 3.75 MG KIT 1/1/ /99/9999

11 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2315 INJECTION, NALTREXONE, DEPOT FORM, 1 MG VIVITROL 380 MG VIAL + DILUENT 7/1/ /99/ J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 10 MG KIT 11/1/ /99/ J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 20 MG KIT 11/1/ /99/ J2353 OCTREOTIDE, INJECTION SANDOSTATIN LAR 30 MG KIT 11/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 8/29/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 9/9/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 8 MG TABLET 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 2/8/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 2 MG/ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ZOFRAN 4 MG/2 ML VIAL 6/1/2009 3/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 32 MG/50 ML BAG 6/1/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML SYR 6/1/2009 3/1/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 3/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 6/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /10/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 32 MG/50 ML BG 6/1/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 8/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 1/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 7/31/2013

12 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/24/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/2009 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON ODT 4 MG TABLET 6/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG TABLET 6/1/2009 1/31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON 40 MG/20 ML VIAL 2/26/ /31/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 1/1/2010 9/30/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 11/1/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL 4 MG/2 ML VIAL 3/8/ /99/ J2405 ODANSETRON HYDROCHLORIDE, PER 1 MG KETOROLAC 30 MG/ML VIAL 6/1/ /99/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 2/26/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 30 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG AREDIA 90 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIA 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIA 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/2008 2/28/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/2008 5/31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/2008 3/31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/2008 3/31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 3/1/ /31/2010

13 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 60 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 3 MG/ML VIA 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 3/1/ /31/ J2430 PAMIDRONATE DISODIUM PER 30 MG OTN PAMIDRONATE 9 MG/ML VIA 3/1/2008 3/31/ J2507 PEGLOTICASE INJECTION KRYSTEXXA 8 MG/ML VIAL 1/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 4.5 GM VIAL 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 11/8/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 11/8/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 2/8/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT GM VL 2/6/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM PIPERACIL-TAZOBACT 2.25 GM VL 1/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2/0.25 GM ADD-VANTAGE VL 4/1/2008 3/31/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GRAM VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 3/0.375 GM ADD-VANTAGE 4/1/2008 6/30/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GRAM VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4/0.5 GM ADD-VANTAGE VL 4/1/2008 6/30/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 40.5 GRAM BULK VIAL 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GM/50 ML GALAXY BAG 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GM/50 ML GALAXY 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 4/1/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 4.5 GM/100 ML GALAXY BAG 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN 2.25 GRAM VIAL 8/30/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GRAM VIAL 7/19/ /99/ J2543 INJECTION, PIPERACILLIN/TAZOBACTAM ZOSYN GRAM VIAL 5/29/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 12/30/ /99/9999

14 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 12/30/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 9/2/2008 1/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 5/29/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 8/16/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML SYRINGE 3/1/ /31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/2/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 6/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/2008 6/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 3/1/2008 3/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 3/1/2008 1/31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 3/1/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 3/1/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 3/1/2008 4/30/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML VIAL 3/1/ /31/2012

15 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML VIAL 3/1/ /31/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 3/1/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/2/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/2/ /99/ J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG DEMEROL 50 MG/ML AMPUL 4/1/ /99/ J2778 Ranibizumab injection LUCENTIS 0.3 MG VIAL 10/1/ /99/ J2778 Ranibizumab injection LUCENTIS 0.5 MG VIAL 9/1/ /99/ J2785 REGADENOSON INJECTION LEXISCAN INJECTION 9/1/ /99/ J2796 INJECTION, ROMIPLOSTIM, 10 MCG NPLATE 250 MCG VIAL 1/1/ /99/ J2796 INJECTION, ROMIPLOSTIM, 10 MCG NPLATE 500 MCG VIAL 1/1/ /99/ J2916 FERRLECIT SOD FER GLUC CPLX 62.5 MG/5 ML 8/16/ /99/ J2916 FERRLECIT NULECIT 62.5 MG/5 ML VIAL 5/25/ /99/ J2916 FERRLECIT FERRLECIT 62.5 MG/5 ML AMPUL 5/7/ /31/ J2916 FERRLECIT FERRLECIT 62.5 MG/5 ML VIAL 7/1/ /99/ J2916 FERRLECIT FERRLECIT 62.5 MG/5 ML AMPUL 1/1/ /31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML SYRINGE 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 9/1/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 5/31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 6/28/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 1/28/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML VIAL 3/1/2008 5/31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/2008 4/30/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/ /31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/2008 7/31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/2008 3/25/2010

16 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG SUBLIMAZE 0.05 MG/ML AMPUL 3/1/2008 9/30/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 3/1/ /99/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/2008 3/31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL CITRATE POWDER 3/1/ /31/ J3010 INJECTION, FENTANYL CITRATE PER 0.1 MG FENTANYL 0.05 MG/ML AMPUL 9/2/2008 4/30/ J3300 TRIAMCINOLONE A INJ PRS-FREE TRIESENCE 40 MG/ML VIAL 3/1/ /99/ J3300 TRIAMCINOLONE A INJ PRS-FREE KENALOG MG/ML VIAL 3/1/ /99/ J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG MG/ML VIAL 1/1/ /99/ J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG MG/ML VIAL 1/1/ /99/ J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG MG/ML VIAL 1/1/ /99/ J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG KENALOG MG/ML VIAL 1/1/ /99/ J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG ARISTOSPAN 20 MG/ML VIAL 1/1/ /99/ J3301 INJECTION TRIAMCINOLONE ACETONIDE, 10 MG ARISTOSPAN 20 MG/ML VIAL 1/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN-D5W 500 MG/100 ML 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 1G/200 ML BAG 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/2009 9/30/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG A-V VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG A-V VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM ADD-VAN VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM ADD-VAN VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 6/1/ /99/ J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 10 GM VIAL 6/1/ /99/ J3490 UNCLASSIFIED DRUGS KADCYLA 160 MG VIAL 4/1/ /31/ J3490 UNCLASSIFIED DRUGS KADCYLA 100 MG VIAL 4/1/ /31/ J3490 UNCLASSIFIED DRUGS SKYLA SYSTEM 1/14/ /31/2013

17 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J3490 UNCLASSIFIED DRUGS OZURDEX 0.7 MG IMPLANT 11/9/2009 1/31/ J3490 UNCLASSIFIED DRUGS TRIESENCE 40 MG/ML VIAL 6/1/2008 1/31/ J3490 UNCLASSIFIED DRUGS PROPOFOL 10 MG/ML VIAL 8/30/ /27/ J3490 UNCLASSIFIED DRUGS MARCAINE 0.25% VIAL 6/1/ /99/ J3590 UNCLASSIFIED BIOLOGICS PERJETA 420 MG/14 ML VIAL 8/29/ /31/ J3590 UNCLASSIFIED BIOLOGICS BERINERT 500 UNIT KIT 2/26/2010 1/31/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /30/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SALINE 0.9% SOLN-EXCEL CONT 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN 3/1/ /31/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN. 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 9/30/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/2008 9/30/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /1/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLN 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% VIAL 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC BACTERIOSTATIC SALINE VIAL 3/1/ /99/ J7050 INFUSION, NORMAL SALINE SOLUTION 250 CC SODIUM CHLORIDE 0.9% SOLUTION 8/3/ /99/ J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 250 UNIT KIT 3/1/2008 3/31/ J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 500AHFU KIT 3/1/2008 3/31/ J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 1,000 UNITS KIT 3/1/ /5/ J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 1,500 UNITS KIT 3/1/ /28/2012

18 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J7190 FACTOR VIII, HUMAN, PER IU MONARC-M UNITS VIAL 3/1/ /31/ J7190 FACTOR VIII, HUMAN, PER IU MONARC-M UNITS VIAL 3/1/ /31/ J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 801-1,700 UNITS VIAL 3/1/ /31/ J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 1,701-2,000 UNITS VL 3/1/ /31/ J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M UNITS VIAL 3/1/ /31/ J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M UNITS VIAL 3/1/2008 8/27/ J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 801-1,700 UNITS VIAL 3/1/ /31/ J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 1,701-2,000 UNITS VL 3/1/ /8/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNIT VIAL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 500 UNIT VIAL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNITS VIAL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 500 UNITS VIAL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 2,000 UNIT VIAL 3/1/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 2,000 UNIT VIAL 3/1/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 250 UNIT VIAL 3/1/ /15/ J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 500 UNIT VIAL 3/1/2008 2/17/ J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 1,000 UNIT VIAL 3/1/2008 2/24/ J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE UNIT VIAL 3/1/ /2/ J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE UNIT VIAL 3/1/2008 4/26/ J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 801-1,240 UNIT VL 3/1/2008 4/26/ J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE UNIT VL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE UNIT VL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 801-1,240 UNITS VL 3/1/ /31/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 250 UNITS VIAL 3/1/2008 2/4/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 500 UNITS VIAL 3/1/2008 2/4/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,000 UNITS VIAL 3/1/2008 2/4/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,500 UNITS VIAL 3/1/2008 2/4/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,800-2,200 UNITS VIAL 3/1/2008 2/4/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE UNITS VIAL 3/1/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE UNITS VIAL 3/1/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 801-1,200 UNITS VIAL 3/1/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,201-1,800 UNITS VIAL 3/1/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,801-2,400 UNITS VIAL 3/1/ /99/9999

19 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 2,401-3,600 UNITS VIAL 3/1/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 1,000 UNITS VIAL 3/1/2008 3/31/ J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 500 UNITS VIAL 3/1/2008 3/31/ J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 250 UNITS VIAL 3/1/2008 3/31/ J7192 FACTOR VIII, RECOMBINANT, PER IU REFACTO 2,000 UNITS VIAL 3/1/2008 3/31/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNIT VIAL 12/30/ /99/ J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 5/15/ /99/ J7301 SKYLA 13.5MG SKYLA SYSTEM 1/1/ /99/ J7312 DEXAMETHASONE INTRA IMPLANT OZURDEX 0.7 MG IMPLANT 2/1/ /99/ J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 11/9/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 6/30/2009 Y

20 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 5/31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/2008 6/30/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 3/1/ /31/2009 Y J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 12/30/ /31/2009 Y J8561 ORAL EVEROLIMUS ZORTRESS 0.5 MG TABLET 1/1/ /31/ J8561 ORAL EVEROLIMUS ZORTRESS 0.75 MG TABLET 1/1/ /31/ J8561 ORAL EVEROLIMUS ZORTRESS 0.25 MG TABLET 1/1/ /31/ J8561 ORAL EVEROLIMUS AFINITOR 10 MG TABLET 1/1/ /31/ J8561 ORAL EVEROLIMUS AFINITOR 2.5 MG TABLET 1/1/ /31/ J8561 ORAL EVEROLIMUS AFINITOR 5 MG TABLET 1/1/ /31/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG VIAL 3/1/2008 6/30/ J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 10 MG VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 20 MG VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 50 MG VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 2 MG/ML VIAL 3/1/ /30/ J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 2 MG/ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 2 MG/ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG ADRIAMYCIN 200 MG/100 ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG VIAL 3/1/2008 6/30/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG VIAL 3/1/2008 5/31/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 3/1/2008 9/30/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 20 MG/10 ML VIAL 3/1/2008 1/31/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 3/1/2008 1/31/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 3/1/ /30/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 20 MG/10 ML VIAL 3/1/ /99/ J9000 DOXORUBICIN HCL, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 3/1/ /99/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 5/15/ /99/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLENOXANE 15 UNITS VIAL 3/1/2008 1/31/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLENOXANE 30 UNITS VIAL 3/1/2008 2/28/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 3/1/ /99/9999

21 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNITS VIA 3/1/2008 3/31/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 3/1/ /99/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNITS VIA 3/1/ /31/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 3/1/2008 9/30/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 3/1/2008 9/30/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 3/1/ /99/ J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 3/1/ /99/ J9043 CABAZITAXEL INJECTION JEVTANA 60 MG/1.5 ML KIT 1/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 12/30/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 12/30/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 12/30/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 5/7/ /99/ J9045 CARBOPLATIN, 50 MG PARAPLATIN 50 MG VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG PARAPLATIN 150 MG VIAL 3/1/2008 5/14/ J9045 CARBOPLATIN, 50 MG PARAPLATIN 450 MG VIAL 3/1/2008 4/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 8/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 4/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 5/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 4/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 5/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 2/28/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 8/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 3/31/2010

22 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/ /31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/ /31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 9/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/2008 9/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 9/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 9/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 9/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 9/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/2008 9/30/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 3/1/2008 3/31/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 3/1/ /99/ J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 3/1/ /99/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 100 MG/100 ML VIAL 8/29/ /99/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 50 MG/50 ML VIAL 3/1/ /99/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 100 MG/100 ML VIAL 3/1/ /99/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 1 MG/ML VIAL 3/1/2008 9/30/2011

23 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9060 CISPLATIN 10 MG INJECTION CISPLATIN 50 MG/50 ML VIAL 3/1/ /99/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 200 MG/200 ML VIAL 3/1/ /99/ J9060 CISPLATIN 10 MG INJECTION CISPLATIN 100 MG/100 ML VIAL 3/1/ /99/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 50 MG/50 ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 100 MG/100 ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 50 MG/50 ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 200 MG/200 ML VIAL 6/1/ /31/ J9062 CISPLATIN, 50 MG VIAL CISPLATIN 100 MG/100 ML VIAL 6/1/ /31/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/8 ML VIAL 8/15/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 160 MG/16 ML VIAL 8/15/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/2 ML VIAL 5/25/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/8 ML VIAL 5/25/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 160 MG/16 ML VIAL 3/17/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 20 MG/ML VIAL 10/11/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 80 MG/4 ML VIAL 10/11/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/ML VIAL 3/14/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/4 ML VIAL 3/14/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 20 MG/0.5 ML VIAL 1/1/2010 5/31/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/0.5 ML VIAL 7/11/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/2 ML VIAL 7/11/ /99/ J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 80 MG/2 ML VIAL 1/1/2010 6/30/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 150 MG/75 ML VIAL 6/1/2009 9/30/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 10 MG/5 ML VIAL 6/1/2009 9/30/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 9/30/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 9/30/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 1/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 10 MG/5 ML VIAL 1/1/2010 3/31/2011

24 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 1/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 150 MG/75 ML VIAL 1/1/2010 3/31/ J9178 EPIRUBICIN, INJECTION ELLENCE 2 MG/ML VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION ELLENCE 2 MG/ML VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 9/30/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/2009 9/30/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/2009 2/28/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/ /31/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN HCL 50 MG VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 200 MG/100 ML VIAL 6/1/ /99/ J9178 EPIRUBICIN, INJECTION EPIRUBICIN 50 MG/25 ML VIAL 6/1/ /99/ J9179 ERIBULIN MESYLATE INJECTION HALAVEN 1 MG/2 ML VIAL 1/1/ /99/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL 50 MG/ML VIAL 5/1/2009 3/31/ J9190 FLUOROURACIL, 500 MG ADRUCIL 50 MG/ML VIAL 5/1/ /99/ J9190 FLUOROURACIL, 500 MG ADRUCIL 50 MG/ML VIAL 5/1/ /99/ J9190 FLUOROURACIL, 500 MG ADRUCIL 5 GRAM/100 ML VIAL 5/1/ /99/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL POWDER 5/1/2009 3/31/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL 500 MG/10 ML VIAL 5/1/ /99/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL 1,000 MG/20 ML VL 5/1/ /99/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL 2,500 MG/50 ML VL 5/1/ /99/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL 5,000 MG/100 ML 5/1/ /99/ J9190 FLUOROURACIL, 500 MG FLUOROURACIL 2,500 MG/50 ML VL 5/15/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 5/7/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 3/31/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 6/30/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/ /31/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 3/31/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 7/30/2010

25 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 500 MG/25 ML VL 6/1/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 9/30/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 9/30/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML INJ 6/1/ /31/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML INJ 6/1/ /30/ J9206 IRINOTECAN CAMPTOSAR 20 MG/ML VIAL 6/1/2009 9/1/ J9206 IRINOTECAN CAMPTOSAR 20 MG/ML VIAL 6/1/2009 6/1/ J9206 IRINOTECAN CAMPTOSAR 100 MG/5 ML VIAL 11/29/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/ /30/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 1/30/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 1/30/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 1/30/ J9206 IRINOTECAN CAMPTOSAR 40 MG/2 ML VIAL 2/28/ /99/ J9206 IRINOTECAN IRINOTECAN HCL 40 MG/2 ML VIAL 6/1/2009 2/1/ J9206 IRINOTECAN IRINOTECAN HCL 100 MG/5 ML VL 6/1/2009 1/1/ J9207 IXABEPILONE INJECTION IXEMPRA 15 MG KIT 4/1/ /99/ J9207 IXABEPILONE INJECTION IXEMPRA 45 MG KIT 4/1/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 45 MG 6MO KIT 8/30/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 22.5 MG SYRINGE 3/1/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 45 MG SYRINGE 3/1/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 30 MG SYRINGE 3/1/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 7.5 MG SYRINGE 3/1/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-4 MONTH KIT 4/17/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 7.5 MG KIT 3/1/ /31/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED MG KIT 3/1/2008 8/1/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 15 MG KIT 3/1/ /1/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 22.5 MG 3MO KIT 3/1/2008 7/1/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 7.5 MG KIT 3/1/2008 8/1/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT MG 3MO KIT 3/1/2008 9/30/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-4 MONTH KIT 3/1/2008 7/1/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON 1 MG/0.2 ML VIAL 3/1/ /1/2009

26 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 22.5 MG 3MO KIT 9/9/ /99/ J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON 2-WK 1 MG/0.2 ML KIT 3/1/2008 1/1/ J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 1 MG/0.2 ML KIT 3/1/2008 3/31/ J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KT 3/1/ /31/ J9218 LEUPROLIDE ACETATE, PER 1 MG LUPRON 1 MG/0.2 ML VIAL 3/1/ /1/ J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KIT 3/1/ /99/ J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 1 MG/0.2 ML VIAL 3/1/2008 3/31/ J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KT 3/1/2008 3/11/ J9218 LEUPROLIDE ACETATE, PER 1 MG LUPRON DEPOT MG 3MO KIT 5/25/ /99/ J9218 LEUPROLIDE ACETATE, PER 1 MG LUPRON 2-WK 1 MG/0.2 ML KIT 3/1/2008 1/1/ J9228 IPILIMUMAB INJECTION YERVOY 50 MG/10 ML VIAL 1/1/ /99/ J9228 IPILIMUMAB INJECTION YERVOY 200 MG/40 ML VIAL 1/1/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 12/31/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 150 MG/25 ML VIAL 12/30/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/2/ /31/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/2/ /31/ J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 5/29/2008 7/6/ J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 5/29/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 5/29/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 5/29/ /99/ J9265 PACLITAXEL 30 MG TAXOL 30 MG/5 ML VIAL 3/1/2008 6/30/ J9265 PACLITAXEL 30 MG TAXOL 100 MG/16.7 ML VIAL 3/1/2008 7/31/ J9265 PACLITAXEL 30 MG TAXOL 300 MG/50 ML VIAL 3/1/2008 7/31/ J9265 PACLITAXEL 30 MG ONXOL 300 MG/50 ML VIAL 3/1/2008 6/30/ J9265 PACLITAXEL 30 MG ONXOL 300 MG/50 ML VIAL 3/1/2008 8/31/ J9265 PACLITAXEL 30 MG ONXOL 30 MG/5 ML VIAL 3/1/2008 7/31/ J9265 PACLITAXEL 30 MG ONXOL 30 MG/5 ML VIAL 3/1/2008 3/31/ J9265 PACLITAXEL 30 MG ONXOL 150 MG/25 ML VIAL 3/1/2008 5/31/ J9265 PACLITAXEL 30 MG ONXOL 150 MG/25 ML VIAL 3/1/2008 4/11/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/ /30/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 3/31/ J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/ /30/2012

27 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 4/30/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/2008 4/30/ J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/2008 3/31/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/2008 6/30/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/ /31/ J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/ /31/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/ /31/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/ /31/ J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 3/1/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 3/1/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 3/1/ /99/ J9265 PACLITAXEL 30 MG ABRAXANE 100 MG VIAL 3/1/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 11/9/ /99/ J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 11/9/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 3/31/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/2009 3/31/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 3/31/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/2009 3/31/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG NOVANTRONE 2 MG/ML VIAL 6/1/ /30/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/2009 9/30/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/2009 9/30/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/2009 9/30/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 6/1/ /99/ J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 6/1/ /99/ J9306 INJECTION, PERTUZUMAB, 1 MG PERJETA 420 MG/14 ML VIAL 1/1/ /99/ J9307 PRALATREXATE INJECTION FOLOTYN 40 MG/2 ML VIAL 4/1/ /99/ J9315 ROMIDEPSIN INJECTION ISTODAX 10 MG VIAL 8/26/ /99/ J9315 ROMIDEPSIN INJECTION ISTODAX 10 MG VIAL 1/1/ /99/9999

28 Updated NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only J9351 TOPOTECAN INJECTION TOPOTECAN HCL 4 MG VIAL 2/8/ /99/ J9351 TOPOTECAN INJECTION HYCAMTIN 4 MG VIAL 1/1/2011 9/30/ J9354 INJ, ADO-TRASTUZUMAB EMT 1MG KADCYLA 160 MG VIAL 1/1/ /99/ J9354 INJ, ADO-TRASTUZUMAB EMT 1MG KADCYLA 100 MG VIAL 1/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 12/30/2008 6/1/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 12/30/2008 6/1/ J9390 VINORELBINE TARTRATE, PER 10 MG NAVELBINE 10 MG/ML VIAL 12/30/2008 6/1/ J9390 VINORELBINE TARTRATE, PER 10 MG NAVELBINE 50 MG/5 ML VIAL 12/30/2008 6/1/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 5/29/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 5/29/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG NAVELBINE 10 MG/ML VIAL 3/1/2008 3/31/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 3/31/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/2008 5/31/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/2008 3/31/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/ /31/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/ /31/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 10 MG/ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/ /99/ J9390 VINORELBINE TARTRATE, PER 10 MG VINORELBINE 50 MG/5 ML VIAL 3/1/ /31/ J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC IXEMPRA 15 MG KIT 3/1/2008 3/31/ J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC IXEMPRA 45 MG KIT 3/1/2008 3/31/ Q2044 BELIMUMAB INJECTION BENLYSTA 120 MG VIAL 7/1/ /99/ Q2044 BELIMUMAB INJECTION BENLYSTA 400 MG VIAL 7/1/ /99/ RSV MAB IM 50MG SYNAGIS 50 MG/0.5 ML VIAL 3/1/ /99/ RSV MAB IM 50MG SYNAGIS 100 MG/1 ML VIAL 3/1/ /99/9999

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