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HCPCS - NDC Crosswalk HCPCS NDC 90378 90378 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 60574411301 60574411401 00074108101 00074158401 00074181222 00074210205 00074402702 00074488750 00074488820 00074536505 00223849602 00223849605 00223849710 00223850030 00264180031 00264180036 00338004910 00338004911 00338004931 00338004941 00338055311 00409108151 00409191832 00409191833 00409191835 00409196604 00409196605 00409196607 00409196612 00409196614 00409210202 00409210205 00409397703 00409402903 00409404402 00409488710 00409488720 00409488750 00409488799 00409488810 00409488812 00409488820 00409488850 00409710166 00409798413 00409798420 00409798436 00487930102 00487930103 00487930133 00517064825 00517066225 00517280225 00517281025 00517300525 00517301025 00517302025 00517305025 08166110903 08166110905 08166110910 08290031002 08290031003 08290031102 12/19/2013 Earliest Start Date HCPCS Description RSV-IGIM, 50MG, (SYNAGIS) RSV-IGIM, 50MG, (SYNAGIS) STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR STERILE WATER, SALINE AND/OR DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML 01/01/2007 01/01/2007 04/25/2005 01/01/2004 01/01/2007 01/01/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2007 01/01/2007 01/01/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 12/27/2006 01/01/2007 01/01/2007 01/01/2007 08/30/2005 05/02/2005 04/05/2005 10/06/2005 06/01/2005 01/01/2007 01/01/2007 04/07/2005 03/01/2005 02/09/2006 08/18/2005 06/16/2005 08/05/2005 08/03/2005 04/22/2005 07/15/2005 02/23/2005 02/14/2005 07/28/2005 06/20/2005 06/17/2005 07/14/2005 01/01/2006 01/01/2006 01/01/2006 01/01/2004 01/01/2004 01/01/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2007 01/01/2007 01/01/2004 01/01/2007 01/01/2007 01/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 11/01/2006 12/31/2078 10/01/2006 10/01/2007 06/01/2008 12/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/01/2011 12/31/2078 12/31/2078 12/31/2078 09/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2012 12/31/2078 01/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 08290031103 08290032003 08290032005 08290032103 08290032105 08290033003 08290033005 08290033006 08290033010 08290033103 08290033105 08290033110 08290091002 08290091003 08290091102 08290091103 08290092005 08290092105 08290093010 08290094010 08290094110 08290095010 08450090102 08450090303 08450090505 08450090610 08450601102 08450601203 08450601305 08450601410 08881570128 08881570129 12280023301 15686011103 15686011105 35356018130 48879000101 48879000102 48879000201 48879000202 48879000301 48879000302 48879000307 49072066930 49502064015 49502081003 49502081005 49502082003 49502082005 49502083003 49502083005 49502083050 50486007822 50486007823 50962065001 53298010106 54569152200 54569307800 54569403700 54868011600 54868018300 54868071005 54868252700 54868397500 54868446400 12/19/2013 HCPCS Description STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, WATER, SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE SALINE AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR AND/OR DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML Earliest Start Date 01/01/2004 01/01/2007 01/01/2007 01/01/2004 01/01/2004 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2007 01/01/2007 01/01/2004 01/01/2004 01/01/2007 01/01/2004 01/01/2007 01/01/2007 01/01/2004 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 07/01/2006 07/01/2006 08/18/2005 04/02/2007 04/02/2007 05/16/2008 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2004 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2004 01/01/2004 01/18/2007 01/01/2006 01/01/2004 01/01/2004 12/15/2006 06/28/2007 01/01/2004 01/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4216 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 54868502600 54868571400 55045371001 58016060301 58016483801 58016499501 58016946401 59930160901 59930160902 63323018500 63323018505 63323018510 63323018520 63323018550 63323018602 63323018610 63323018620 63323024930 63323025910 63323025930 63323092410 63323092430 63807010011 63807010020 63807010030 63807010033 63807010035 63807010050 63807010051 63807010055 63807010056 63807010075 63807010092 63807010211 64054090203 64054090302 64054090306 64054090502 64054090506 64054091002 64253011121 64253011122 64253011123 64253011125 64253011130 64253011133 64253011135 68883090001 68883090003 68883090004 68883090005 68883090010 68883090016 83490010760 00074614736 00264210100 00264210110 00264210150 00264210170 00264220100 00264220110 00264220150 00264220170 00264785000 00264785010 12/19/2013 HCPCS Description STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE STERILE WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER, SALINE AND/OR WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML WATER/SALINE, 500 ML DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DEXTROSE, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, DILUENT/FLUSH, 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML ML Earliest Start Date 01/01/2006 12/11/2006 01/01/2007 01/01/2006 02/01/2006 01/01/2007 01/01/2004 01/01/2006 01/01/2006 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2007 04/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 04/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 10/01/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/30/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4217 A4218 C9272 C9272 C9276 G9017 J0120 J0128 J0129 J0130 J0132 00264785020 00264920055 00264920155 00264920555 00338000344 00338000346 00338000347 00338000349 00338000402 00338000403 00338000404 00338000405 00338001304 00338001306 00338001308 00338001329 00338004146 00338004724 00338004727 00338004729 00338004744 00338004746 00338004747 00338004802 00338004803 00338004804 00338004805 00338005047 00409159002 00409159005 00409402702 00409613803 00409613822 00409613903 00409613922 00409711807 00409713809 00409713836 00409713909 00409713936 00409797205 00409797207 00409797208 00409797305 00409797307 00409797308 00409797507 00409799009 08080100000 08080102000 08080102200 54868071002 54868390500 54868429600 54868431100 49502050120 55513071001 55513073001 00024582411 00781204805 51927244900 68158014951 00003218710 00002714001 66220010730 12/19/2013 HCPCS Description STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE WATER/SALINE, 500 ML STERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 ML DENOSUMAB, PER 1 MG INJECTION, DENOSUMAB, 1 MG CABAZITAXEL, PER 1MG AMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE IN A MED INJECTION, TETRACYCLINE, UP TO 250 MG INJECTION, ABARELIX, 10 MG INJECTION, ABATACEPT, 10 MG INJECTION ABCIXIMAB, 10 MG INJECTION, ACETYLCYSTEINE, 100 MG Earliest Start Date 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 08/05/2005 06/28/2005 05/26/2006 06/01/2005 09/01/2005 05/09/2005 05/04/2005 08/16/2005 05/11/2005 06/09/2005 03/02/2005 05/04/2005 09/01/2005 04/05/2005 05/18/2005 03/16/2005 08/09/2005 07/14/2005 04/26/2006 09/02/2005 03/01/2006 03/01/2006 03/01/2006 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2006 06/05/2010 06/05/2010 01/01/2011 01/20/2005 09/08/2003 01/01/2005 01/01/2006 01/01/2002 01/01/2006 Latest End Date 12/31/2078 08/31/2013 09/30/2013 02/28/2011 12/31/2078 12/31/2078 12/31/2078 05/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/01/2011 03/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0133 J0135 J0135 J0135 J0135 J0135 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0150 J0152 J0152 J0152 J0152 J0152 J0152 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 38779017301 38779017304 38779017305 38779017308 49452000103 49452000104 51552067101 51552067102 51552067103 51552067104 51552067105 51552067106 51927299400 55390061210 55390061320 62991100401 62991100402 63323010510 63323032510 63323032520 63370000725 63370000735 63370000750 00074379902 00074433902 00074433906 00074937402 54868482200 00469823412 00469823414 00703877103 00703877301 10019006302 10019006303 10019006307 10019006308 10019006334 25021030102 54569561000 54868555100 55390006710 55390006801 63323065102 63323065104 00469087120 00469087130 51927211600 51927213200 54868582500 54868582501 00074492134 00074724101 00143998490 00409490118 00409492134 00409724101 00517107125 00517113005 00548101400 00548101600 00548201600 00548331600 00548906100 13436070001 13436070002 12/19/2013 HCPCS Description INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ADALIMUMAB, 20 MG INJECTION, ADALIMUMAB, 20 MG INJECTION, ADALIMUMAB, 20 MG INJECTION, ADALIMUMAB, 20 MG INJECTION, ADALIMUMAB, 20 MG INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U ADENOSINE, PER 6 MG INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE U INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE US INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE US INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE US INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE US INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE US INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE US INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE Earliest Start Date 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2005 07/17/2006 02/27/2007 02/22/2008 01/01/2005 06/14/2002 06/14/2002 06/16/2004 06/16/2004 05/05/2007 06/17/2004 05/24/2005 05/24/2005 05/05/2007 11/24/2009 09/30/2004 03/16/2006 06/16/2004 09/01/2004 06/27/2005 06/27/2005 01/01/2004 01/01/2004 01/01/2004 01/01/2004 10/18/2007 10/18/2007 01/01/2002 04/09/2002 07/20/2005 09/23/2005 12/23/2005 09/13/2005 01/01/2002 08/01/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/03/2005 08/03/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2011 09/30/2011 03/31/2013 03/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2007 06/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2009 05/31/2011 09/30/2011 01/31/2014 07/31/2014 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0170 J0171 J0171 J0180 J0180 J0205 J0207 J0207 J0207 J0207 J0207 J0210 J0215 J0215 J0215 J0215 J0257 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 J0270 13436070101 13436070102 23490549702 42023010101 42023012225 49502050001 54569594600 54569594900 54868136300 54868206500 54868206501 54868364100 54868572500 55045369603 55045990303 61570040111 61570041881 66860002001 66860002102 00409492134 00409724101 58468004001 58468004101 58468106001 55390030803 58178001701 58178001703 62756058140 62756058142 00517890510 00469002103 00469002104 59627002103 59627002104 00944288401 00009316906 00009370105 00009377805 00009518101 00009518201 00009765002 00009768604 00091111016 00091111020 00091112016 00091112020 00091114016 00091114020 00703150102 38779094407 38779094409 49452007303 49452007304 51552049801 51552049803 51552049805 51552049809 51927219600 54868489000 55390050310 55390050610 62991112802 62991112806 62991112807 62991112808 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN(EPINEPHRINE) UP TO 1 ML ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE ADRENALIN, EPINEPHRINE, 0.1 MG ADRENALIN, EPINEPHRINE, 0.1 MG AGALSIDASE BETA, 1 MG AGALSIDASE BETA, 1 MG ALGLUCERASE, PER 10 UNITS AMIFOSTINE, 500 MG AMIFOSTINE, 500 MG AMIFOSTINE, 500 MG AMIFOSTINE, 500 MG AMIFOSTINE, 500 MG METHYLDOPATE HCL, UP TO 250 MG ALEFACEPT, 0.5 MG ALEFACEPT, 0.5 MG ALEFACEPT, 0.5 MG ALEFACEPT, 0.5 MG ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC Earliest Start Date 08/03/2005 08/03/2005 04/30/2007 02/28/2008 06/04/2008 01/01/2010 08/13/2007 08/14/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/11/2006 08/17/2006 03/15/2003 09/07/2002 01/01/2002 01/01/2003 01/01/2002 09/30/1990 09/30/1990 01/01/2005 01/01/2005 01/01/2002 04/08/2008 01/01/2002 01/01/2002 03/26/2008 03/26/2008 02/26/2003 02/28/2008 12/31/2007 01/01/2004 01/01/2004 01/01/2012 01/01/2002 01/01/2002 01/01/2002 06/25/2002 06/25/2002 01/01/2002 01/01/2002 09/02/2004 09/02/2004 09/02/2004 09/02/2004 09/02/2004 09/02/2004 01/01/2002 01/01/2002 01/01/2002 02/05/2002 11/15/2004 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 08/28/2003 01/01/2002 01/01/2002 09/15/2003 09/15/2003 09/15/2003 09/15/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2009 05/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2013 05/31/2013 08/31/2008 06/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/08/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 62541011006 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC 01/01/2002 03/31/2012 J0275 62541012001 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC 01/01/2002 12/31/2012 J0275 62541012006 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC 01/01/2002 12/31/2012 J0275 62541013001 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC 01/01/2002 07/31/2013 J0275 62541013006 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC 01/01/2002 07/31/2013 J0275 62541014001 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC 01/01/2002 07/31/2013 J0275 62541014006 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC 01/01/2002 07/31/2013 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0278 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 J0280 00015301520 00015302320 00409195501 00409195601 00409195701 00703903203 00703904003 38779029503 38779029504 38779029505 51927270400 54569591000 55390022302 55390022402 55390022404 55390022502 55390022602 55390022604 62991200201 62991200202 62991200203 63370001615 63370001625 63370001635 63370001650 00074490918 00409592101 00409592201 00409738501 00409738601 00517381025 00517382025 17317002201 17317002204 17317002205 38779057105 38779057108 49452043001 49452043002 49452043006 51552031305 51552031306 51927144400 54868000400 62991200301 62991200302 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 05/07/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2002 04/25/2005 12/24/2004 12/29/2005 11/29/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 12/31/2078 12/31/2078 12/31/2078 11/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 HCPCS NDC J0270 J0270 J0270 J0270 J0275 63275998809 63370021004 63370021006 63370021010 62541011001 J0275 12/19/2013 HCPCS Description INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDIC ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDIC INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMIKACIN SULFATE, 100 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG AMINOPHYLLIN, UP TO 250 MG 12/04/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2012 Page 1 of 1 HCPCS NDC J0280 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0282 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0285 J0287 J0288 J0288 J0288 J0289 J0290 J0290 J0290 62991200303 00074434835 00409434835 00548338000 00703133501 10019013301 10019013302 10019013304 10019013313 10019013319 51927376000 54868572200 55390005701 55390005710 55390009710 55390010501 60505072200 60505072201 61703024103 63323061603 63323061609 63323061613 67457015303 67457015309 67457015318 00013140544 00703978501 38779019103 38779019104 38779019105 38779019106 38779019108 38779019109 39822105505 39822105507 49452002301 49452002302 49452002303 51552030401 51552030402 51552030403 51552030404 51552030405 51552030406 51552030407 51552030409 51927172600 54868575200 62263041411 62991117302 62991117304 62991117305 63370002010 63370002015 63370002025 63370002035 63370002050 57665010141 64116002101 66435030151 66435030201 00469305130 00015740220 00015740320 00015740418 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, AMINOPHYLLIN, UP TO 250 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMIODARONE HYDROCHLORIDE, 30 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B, 50 MG AMPHOTERICIN B LIPID COMPLEX, 10 MG AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG AMPHOTERICIN B LIPOSOME, 10 MG AMPICILLIN SODIUM, 500 MG AMPICILLIN SODIUM, 500 MG AMPICILLIN SODIUM, 500 MG Earliest Start Date 01/01/2002 05/01/2004 09/27/2006 02/01/2004 12/04/2003 11/20/2003 11/20/2003 06/16/2004 05/05/2007 05/05/2007 01/04/2008 12/11/2006 10/25/2002 12/01/2003 03/05/2008 09/07/2005 06/01/2003 12/20/2005 02/12/2003 08/02/2002 12/16/2003 01/06/2003 07/01/2005 11/29/2005 11/29/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/27/2003 01/01/2002 01/01/2002 01/01/2002 03/20/2006 01/24/2002 01/24/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/25/2007 09/07/2004 01/01/2002 01/01/2002 01/01/2008 07/08/2003 09/04/2002 09/04/2002 09/04/2002 09/04/2002 01/01/2004 01/01/2003 11/01/2006 08/14/2008 01/01/2003 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 04/01/2007 12/31/2078 12/31/2078 02/28/2011 10/30/2009 05/30/2010 11/30/2009 10/30/2009 11/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0290 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 00015740489 00015740518 00015740520 00015740589 00781340095 00781340278 00781340295 00781340495 00781340795 00781340895 00781340995 00781341292 00781341392 00781940178 00781940195 00781940278 00781940295 00781940485 00781940495 00781940778 00781940795 00781940880 00781940892 00781940895 00781940995 00781940996 00781941215 00781941292 00781941392 25021013720 54868348100 54868404700 63323038710 63323038810 63323038910 63323039923 00049001383 00049001483 00049002283 00049002383 00049002428 00049003183 00049003283 00409268715 00409268901 00409268911 00409298703 00409298713 00409298801 00409299803 00781303295 00781303395 00781303446 10019063002 10019063033 10019063101 10019063131 10019063203 10019063302 10019063333 10019063401 10019063431 10019063503 10019063601 10019063631 12/19/2013 Earliest Start Date HCPCS Description INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG AMPICILLIN SODIUM, 500MG INJECTION INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG AMPICILLIN SODIUM, 500MG INJECTION INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM GM 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/12/2004 01/01/2009 12/01/2005 12/01/2005 12/01/2005 12/01/2005 05/12/2004 03/20/2007 03/20/2007 02/01/2007 02/01/2006 01/24/2006 02/01/2006 01/24/2006 02/01/2006 01/24/2006 02/01/2006 01/24/2006 02/01/2007 02/01/2006 02/01/2006 02/01/2007 02/01/2007 03/20/2007 03/20/2007 09/21/2010 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/22/2007 10/09/2006 07/01/2007 10/09/2006 07/01/2007 07/20/2007 07/20/2007 09/05/2006 09/05/2006 09/05/2006 12/15/2003 05/05/2007 11/18/2005 05/05/2007 11/18/2005 03/10/2006 05/05/2007 03/10/2006 05/05/2007 12/14/2005 05/02/2006 05/05/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2013 12/31/2013 12/31/2078 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2013 10/31/2013 10/31/2013 10/31/2013 10/31/2013 07/31/2013 07/31/2013 07/31/2013 07/31/2013 02/28/2013 10/31/2013 10/31/2013 Page 1 of 1 HCPCS NDC J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0295 J0300 J0330 J0330 J0330 J0330 J0330 J0330 J0330 J0330 J0348 J0360 J0360 J0360 J0360 J0360 J0360 J0360 J0360 J0360 J0360 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0364 J0365 J0365 J0400 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 J0456 10019063702 10019063733 10019063803 10139007011 10139007110 25021014330 63323036820 63323036920 63323037062 63304030310 00074662902 00074697010 00074806515 00409662902 00409662961 00409697010 00781300995 51927353600 00049101028 00517090125 17478093401 49452354401 49452354402 49452354403 49452354503 51552080202 51927197900 63323061401 63323061455 16887021101 16887021105 38779176400 38779176403 38779176406 51552065201 51552065202 51552065204 51927230300 62991151301 62991151302 62991151303 63370002206 63370002209 63370002215 00026819636 00026819763 59148001665 00069315014 00069315083 00409014411 00703908503 00703908901 10019064802 10019064871 25021011210 50111079478 54868452700 62991257701 62991257702 62991257703 63275996502 63275996503 63275996504 63275996505 63323039810 12/19/2013 HCPCS Description INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER AMPICILLIN NA/ SULBACTAM 1.5GM INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER INJECTION, AMOBARBITAL, UP TO 125 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, ANIDULAFUNGIN, 1 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20MG INJ INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APROTONIN, 10,000 KIU INJECTION, APROTONIN, 10,000 KIU INJECTION, ARIPIPRAZOLE, INTRAMUSCULAR, 0.25 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG AZITHROMYCIN INJ, PER 500MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG AZITHROMYCIN INJ, PER 500MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, AZITHROMYCIN, 500 MG 1.5 1.5 1.5 1.5 1.5 GM GM GM GM GM 1.5 GM 1.5 GM 1.5 GM Earliest Start Date 05/02/2006 05/05/2007 05/02/2006 07/03/2007 07/03/2007 08/13/2010 11/30/2005 11/30/2005 11/08/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/25/2005 04/20/2006 09/30/2005 04/15/2005 09/08/2003 01/01/2007 01/01/2002 11/06/2009 02/04/2002 02/04/2002 04/01/2005 02/04/2002 09/01/2003 09/08/2003 01/01/2002 03/26/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2006 01/01/2006 01/01/2008 02/25/2002 01/01/2002 06/26/2009 03/01/2007 03/01/2007 04/12/2006 05/05/2007 05/01/2009 07/25/2007 01/01/2002 10/01/2007 10/01/2007 10/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 02/27/2006 Latest End Date 10/31/2013 10/31/2013 10/31/2013 12/31/2078 02/28/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2006 04/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/01/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2010 02/28/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2014 12/31/2078 12/31/2078 07/31/2010 11/30/2011 01/13/2012 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0456 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0460 J0470 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0475 J0476 J0480 J0480 J0485 63323039812 00074491134 00223719125 00223719200 00223719325 00223720601 00409163010 00409491034 00409491134 00409962905 00409963005 00517010125 00517040125 00517080525 00517101025 00548103900 00548203900 00548333800 00548333900 10019025012 10019025020 10019025037 10019025039 10019025112 10019025139 54569560700 54868000600 54868074000 54868074001 54868389300 63323023401 63323023420 63323024601 11098052603 38779038803 38779038804 38779038805 38779038809 49452080702 49452080703 49452080704 51552061302 51552061304 51552061305 51927200700 58281056001 58281056002 58281056102 58281056301 58281056302 62991101301 62991101302 62991101303 62991101304 63275999202 63275999204 63275999205 63370002615 63370002625 63370002635 63370002645 58281056201 00078033184 00078039361 00003037113 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, AZITHROMYCIN, 500 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG ATROPINE SULFATE, UP TO 0.3 MG DIMERCAPROL, PER 100 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 10 MG BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL BASILIXIMAB, 20 MG BASILIXIMAB, 20 MG BELATACEPT, 1MG Earliest Start Date 02/27/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/11/2006 08/18/2005 11/14/2005 04/26/2006 10/19/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/09/1997 09/09/1997 01/01/2002 09/09/1997 09/29/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/22/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 04/02/2004 01/01/2002 10/21/2003 04/02/2004 01/01/2002 01/01/2002 01/01/2002 09/15/2003 12/04/2002 12/04/2002 12/04/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2006 01/01/2006 01/01/2013 Latest End Date 12/31/2078 08/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2012 12/31/2078 03/31/2012 12/31/2078 01/31/2011 02/28/2011 09/30/2009 12/31/2013 12/31/2013 12/31/2013 12/31/2013 12/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2009 09/30/2010 12/31/2078 02/28/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0490 J0490 J0500 J0500 J0500 J0500 J0500 J0500 J0515 J0515 J0515 J0515 J0515 J0515 J0515 J0515 J0515 J0515 J0520 J0520 J0520 J0520 J0520 J0520 J0520 J0520 J0520 J0520 J0520 J0520 J0530 J0530 J0530 J0530 J0530 J0530 J0540 J0540 J0540 J0540 J0540 J0540 J0540 J0540 J0540 J0540 J0540 J0540 J0550 J0550 J0550 J0550 J0550 J0550 J0560 J0560 J0560 J0560 J0560 J0560 J0560 J0560 J0560 J0560 J0560 49401010101 49401010201 00068080923 00463110410 51552074104 51927134700 55390006610 58914008052 00143972905 38779019403 38779019404 38779019406 49452101601 49452101602 49452101603 51552095201 54868242901 67386061152 38779039303 38779039304 38779039305 38779039306 49452108301 49452108302 49452108303 51552087902 51552087904 51927209700 62991153002 62991153003 61570013910 61570014010 61570014110 61570014210 61570014310 61570014410 54569595700 54569595800 55045368402 60793060010 60793060110 60793060210 61570013910 61570014010 61570014110 61570014210 61570014310 61570014410 61570013910 61570014010 61570014110 61570014210 61570014310 61570014410 54569140901 54569587600 54569587700 54569587701 54868075300 54868075301 54868246600 54868334900 60793070010 60793070110 60793070210 12/19/2013 HCPCS Description BELIMUMAB PER 10MG BELIMUMAB PER 10MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG BENZTROPINE MES. INJ. PER 1MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE 600000 UNITS INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE 600000 UNITS 600000 UNITS INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE UP TO 2400000 UNITS UP TO 2400000 UNITS UP TO 2400000 UNITS UP TO 2400000 UNITS UP TO 2400000 UNITS UP TO 2400000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS Earliest Start Date 01/01/2012 01/01/2012 01/01/2002 01/01/2002 09/01/2003 09/08/2003 07/14/2003 06/22/2004 04/01/2010 01/01/2002 04/19/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2005 09/01/2003 01/01/2002 01/21/2006 01/01/2002 01/01/2002 04/19/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/08/2003 09/15/2003 09/15/2003 01/19/2002 01/01/2002 01/01/2006 01/01/2002 01/01/2006 01/01/2006 09/05/2007 09/05/2007 11/15/2005 08/15/2007 08/15/2007 08/15/2007 01/01/2006 01/01/2002 05/29/2002 01/01/2006 01/01/2002 01/01/2002 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2002 01/17/2007 01/17/2007 01/17/2007 01/01/2002 01/01/2002 06/12/2006 01/01/2002 11/21/2006 11/21/2006 11/21/2006 Latest End Date 12/31/2078 12/31/2078 09/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0570 J0570 J0570 J0570 J0570 J0570 J0580 J0580 J0580 J0580 J0580 J0580 J0583 J0585 J0585 J0585 J0585 J0587 J0587 J0587 J0588 J0588 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0592 J0594 J0594 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0595 60793060010 60793070010 60793070110 61570014610 61570014710 61570014810 60793070010 60793070110 60793070210 61570014610 61570014710 61570014810 65293000101 00023114501 00023392102 00023923201 54868412300 10454071010 10454071110 10454071210 00259160501 00259161001 00409201232 12496075701 38779088800 38779088806 38779088809 49452825301 49452825302 49452825303 49452825304 51927101200 55390010010 62991158301 62991158302 62991158303 63370090506 63370090509 63370090510 63370090515 67286005308 67286005408 00015564520 00015564620 00074230101 00074230201 00409162301 00409162349 00409162601 00409162602 00409162649 00409162651 10019046101 10019046201 23490518602 49452131701 49452131702 51927298600 54868018600 55045253300 55045296801 55045296802 55390018301 55390018401 55390018402 12/19/2013 Earliest Start Date HCPCS Description PEN G BENZ, 1.2 MILLION UNITS PEN G BENZ, 1.2 MILLION UNITS PEN G BENZ, 1.2 MILLION UNITS UP TO 1200000 UNITS UP TO 1200000 UNITS UP TO 1200000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UP TO 2400000 UNITS UP TO 2400000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 INJECTION, BIVALIRUDIN, 1 MG INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTULINUM TOXIN A, PER 1 UNIT INJECTION, ONABOTULINUMTOXINA, 1 UNIT INJECTION, ONABOTULINUMTOXINA, 1 UNIT INJECTION, RIMABOTULINUMTOXINB, 100 UNITS INJECTION, RIMABOTULINUMTOXINB, 100 UNITS INJECTION, RIMABOTULINUMTOXINB, 100 UNITS INJ, INCOBOTULINUMTOXIN A, 1 UNIT INJ, INCOBOTULINUMTOXIN A, 1 UNIT INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUSULFAN, 1 MG INJECTION, BUSULFAN, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG UNITS UNITS UNITS UNITS 09/30/1990 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2004 01/01/2002 01/01/2010 06/07/2002 01/01/2002 08/01/2005 08/01/2005 06/30/2006 01/01/2012 01/01/2012 06/17/2005 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2004 09/08/2003 06/03/2005 09/15/2003 09/15/2003 09/15/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2007 07/30/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 09/20/2005 10/19/2005 03/21/2006 12/21/2005 05/24/2006 12/08/2005 01/01/2004 01/01/2004 04/09/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2005 04/11/2006 01/01/2004 01/01/2004 01/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 10/31/2007 12/31/2007 10/31/2007 12/31/2078 12/31/2078 12/31/2078 10/31/2007 12/31/2007 10/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0595 J0595 J0595 J0595 J0595 J0595 J0595 J0597 J0598 J0600 J0600 J0600 J0600 J0600 J0600 J0600 J0610 J0610 J0610 J0610 J0610 J0610 J0610 J0620 J0630 J0636 J0636 J0636 J0636 J0636 J0636 J0636 J0637 J0637 J0638 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0640 J0641 J0670 J0670 J0670 J0670 J0670 J0670 J0670 J0670 J0670 J0670 55390018510 58016486801 60505065800 60505065900 60505066000 61703031745 61703031845 63833082502 42227008105 00089051006 17317240902 49452269701 49452269702 49452269703 51552043505 51927205900 00517390025 00517391025 00517395025 63323031110 63323031150 63323031161 63323031163 00516006060 00078014923 00074811031 00517013225 00703731104 51927342200 61703023429 63323073101 68830031980 00006382210 00006382310 00078058261 00703279301 00703279701 00703514001 00703514501 49452403601 49452403602 49452403604 51927269200 55390000901 55390005110 55390005210 55390005301 55390005401 55390081810 55390082401 55390082501 55390082601 63323071050 63323071100 68152010100 00074103850 00074106720 00074204750 00186041001 00186041201 00186041801 00186042001 00186042201 00409103630 00409103850 12/19/2013 HCPCS Description INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNIT INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER INJECTION, CALCITONIN SALMON, UP TO 400 UNITS INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CASPOFUNGIN ACETATE, 5 MG INJECTION, CASPOFUNGIN ACETATE, 5 MG INJECTION, CANAKINUMAB, 1 MG LEUCOVORIN CALCIUM PER 50MG LEUCOVORIN CALCIUM PER 50MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM PER 50MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML Earliest Start Date 01/01/2004 03/15/2006 01/01/2004 01/01/2004 01/01/2004 06/25/2004 06/25/2004 12/03/2009 12/15/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 12/04/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2003 03/14/2005 01/17/2005 09/08/2003 04/02/2004 03/17/2003 09/17/2003 01/01/2003 01/01/2003 01/01/2012 07/08/2011 07/13/2011 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/16/2002 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/08/2000 01/01/2002 08/15/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/21/2006 10/08/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2014 04/30/2014 05/31/2013 06/30/2013 12/31/2078 12/31/2078 12/31/2078 10/01/2008 09/01/2008 10/01/2008 12/31/2011 12/31/2078 08/31/2011 09/30/2011 03/31/2012 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0670 J0670 J0670 J0670 J0670 J0670 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0690 J0692 J0692 J0692 J0692 J0692 J0692 J0692 00409104130 00409106720 00409204750 00409755101 66312044014 66312046014 00015733812 00069031220 00074473203 00264310211 00264310311 00264310511 00338350341 00409080501 00409258501 00591236569 00591354969 00591355068 00781333870 00781334646 00781345095 00781345196 00781345295 00781933746 00781933795 00781933885 00781933895 00781933985 00781933996 00781945196 00781945295 10019061001 10019061010 10019061103 10019061110 10019061205 10019061211 54868055900 54868465100 55045323201 60505074804 60505074805 60505074904 60505074905 60505076900 63304094025 63304094110 63323023610 63323023710 63323023765 63323023861 63323044661 66288110001 66288130001 66860000103 66860000203 66860000302 66860090203 00264319511 00781322280 00781322295 00781322391 00781322395 25021012250 51479005301 12/19/2013 HCPCS Description INJECTION, MEPIVACAINE HYDROCHLORIDE, PER INJECTION, MEPIVACAINE HYDROCHLORIDE, PER INJECTION, MEPIVACAINE HYDROCHLORIDE, PER INJECTION, MEPIVACAINE HYDROCHLORIDE, PER INJECTION, MEPIVACAINE HYDROCHLORIDE, PER INJECTION, MEPIVACAINE HYDROCHLORIDE, PER INJECTION, CEFAZOLIN SODIUM, 500 MG CEFAZOLIN, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG CEFAZOLIN, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG CEFAZOLIN, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG CEFEPIME INJ, PER 500MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG 10 10 10 10 10 10 ML ML ML ML ML ML Earliest Start Date 04/26/2006 01/15/2007 09/22/2006 05/05/2008 08/15/2006 08/15/2006 01/01/2002 10/07/2009 01/01/2002 01/01/2002 03/05/2003 01/01/2012 01/01/2002 03/27/2009 06/27/2007 01/22/2003 01/03/2007 08/25/2006 08/23/2004 06/18/2004 11/08/2006 09/13/2006 09/13/2006 04/25/2007 04/25/2007 02/27/2006 02/27/2006 05/15/2007 05/15/2007 01/04/2007 01/09/2007 03/01/2004 05/05/2007 03/01/2004 05/05/2007 10/05/2006 05/05/2007 01/01/2002 09/15/2003 09/01/2004 09/19/2005 09/19/2005 09/19/2005 09/16/2005 06/13/2006 12/07/2004 04/13/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/01/2002 10/01/2002 07/10/2002 07/10/2002 06/01/2002 09/01/2005 10/12/2010 04/14/2008 04/14/2008 04/14/2008 04/14/2008 04/01/2008 11/08/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2012 03/01/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2008 04/30/2010 10/31/2009 12/31/2078 04/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2014 12/31/2078 12/31/2078 12/31/2078 06/30/2014 09/30/2008 11/30/2008 01/13/2012 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2010 06/30/2010 12/31/2078 12/31/2078 11/30/2006 12/31/2078 03/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0692 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0694 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 51479005310 51479005401 51479005402 51479005403 51479005410 51479005420 51479005430 51479005501 51479005502 51479005503 51479005510 51479005520 51479005530 60505068100 60505068104 60505083400 60505083404 60505603004 60505603104 63323032620 63323034020 63323034050 00006354524 00006354725 00264312311 00264312511 10019066071 10019066127 10019066211 25021010910 60505075905 60505076005 60505076104 60505602505 60505602605 63323034120 63323034125 63323034220 63323034361 00004196301 00004196302 00004196401 00004196404 00004196501 00004196505 00069448210 00264315311 00264315511 00338500241 00338500341 00409733201 00409733304 00409733349 00409733410 00409733503 00409733604 00409733649 00409733701 00409733801 00517871110 00517872210 00517872510 00517875010 00703031503 00703032503 12/19/2013 HCPCS Description INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG CEFEPIME INJ, PER 500MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG CEFTRIAXONE 250MG INJ INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG Earliest Start Date 11/08/2002 11/08/2002 11/08/2002 11/08/2002 01/01/2002 01/01/2002 01/01/2002 11/08/2002 11/08/2002 11/08/2002 01/01/2002 01/01/2002 01/01/2002 06/19/2007 06/19/2007 06/19/2007 06/19/2007 04/11/2008 04/11/2008 03/17/2008 03/26/2008 03/17/2008 01/01/2002 01/01/2002 07/01/2006 07/01/2006 05/05/2007 05/05/2007 05/05/2007 12/08/2009 01/23/2006 01/23/2006 02/13/2006 02/27/2008 02/27/2008 01/01/2002 07/01/2011 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/01/2009 07/20/2005 07/20/2005 09/06/2005 09/06/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 05/06/2008 05/06/2008 05/06/2008 05/06/2008 12/21/2007 12/21/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2007 08/30/2012 12/31/2010 12/31/2078 12/31/2078 12/31/2078 11/30/2012 12/31/2078 12/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/30/2012 12/31/2078 08/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2008 12/31/2078 05/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2013 09/30/2011 Page 1 of 1 HCPCS NDC J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 00703033504 00703034603 00703035901 00781320685 00781320695 00781320785 00781320795 00781320885 00781320895 00781320995 00781321046 00781932695 00781932785 00781932795 00781932885 00781932895 00781932990 00781932995 00781933046 10019009801 10019009871 10019068501 10019068571 10019068602 10019068671 10019068703 10019068771 10019068804 10019068827 10019068905 12280007310 21695020210 35356017715 49999058601 49999058610 54569137700 54569572000 54569572100 54569572200 54569572300 54569572400 54569572500 54868093400 54868093401 54868248801 54868322100 54868322101 54868553300 54868558900 55045350301 55045351101 55045351102 55045351601 55390030910 55390031110 55390031210 58016478601 58016479001 58016483401 58016943801 58016945301 58016955101 60505067905 60505067908 60505067909 12/19/2013 HCPCS Description INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, CEFTRIAXONE, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, CEFTRIAXONE, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, CEFTRIAXONE, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, CEFTRIAXONE, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, CEFTRIAXONE, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, CEFTRIAXONE 250MG INJ CEFTRIAXONE, PER 250 MG CEFTRIAXONE, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, INJECTION, CEFTRIAXONE SODIUM, PER 250 MG PER 250 MG PER 250 MG PER 250 MG PER 250 MG PER PER PER PER 250 250 250 250 MG MG MG MG PER 250 MG PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 250 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG PER PER PER PER PER PER PER PER PER 250 250 250 250 250 250 250 250 250 MG MG MG MG MG MG MG MG MG Earliest Start Date 12/21/2007 12/21/2007 12/21/2007 01/01/2006 07/19/2005 01/01/2006 07/19/2005 01/01/2006 07/19/2005 07/19/2005 07/19/2005 07/19/2005 01/01/2007 07/19/2005 01/01/2007 07/19/2005 03/31/2007 07/19/2005 07/19/2005 07/05/2005 05/05/2007 07/05/2005 05/05/2007 07/05/2005 05/05/2007 07/05/2005 05/05/2007 07/05/2005 05/05/2007 10/05/2006 03/21/2005 02/01/2007 05/16/2008 02/24/2005 02/24/2005 01/01/2002 07/26/2005 07/26/2005 07/26/2005 07/27/2005 07/27/2005 07/27/2005 01/01/2002 06/11/2003 01/01/2002 01/01/2002 01/01/2002 02/17/2006 05/12/2006 06/28/2006 07/11/2006 07/14/2006 07/12/2006 07/29/2009 07/20/2009 07/20/2009 02/01/2006 02/01/2006 02/01/2006 02/22/2002 01/01/2002 01/01/2002 09/01/2005 09/01/2005 09/01/2005 Latest End Date 04/30/2013 01/31/2013 01/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2015 06/30/2015 12/31/2078 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0696 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 J0697 60505075000 60505075004 60505075100 60505075104 60505075200 60505075204 60505075300 60505075304 63323034410 63323034510 63323034610 63323034720 63323034861 64679070101 64679070102 64679070103 64679070201 64679070202 64679070301 64679070302 64679098301 64679098302 68180061101 68180061110 68180062201 68180062210 68180063301 68180063310 68180064401 68180064410 68330000101 68330000110 68330000201 68330000210 68330000301 68330000310 68330000401 68330000410 68330000501 68330000601 00173035210 00173035332 00173035410 00173035632 00173040000 00173042400 00173042500 00173043600 00173043700 00264311211 00264311411 00409080201 00781920570 00781920680 00781920746 10019062001 10019062010 10019062103 10019062120 10019062205 10019062211 63323035210 63323035320 63323035461 66860003003 12/19/2013 Earliest Start Date HCPCS Description INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 CEFUROXIME, INJ, PER 750MG INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG 08/02/2005 08/02/2005 08/02/2005 08/02/2005 08/02/2005 08/02/2005 08/02/2005 08/02/2005 02/16/2006 02/16/2006 02/16/2006 02/16/2006 02/16/2006 05/18/2007 05/18/2007 05/18/2007 05/18/2007 05/18/2007 05/18/2007 05/18/2007 05/26/2006 05/26/2006 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 07/20/2005 09/15/2007 09/15/2007 09/15/2007 09/15/2007 09/15/2007 09/15/2007 09/15/2007 09/15/2007 11/05/2007 11/05/2007 02/01/2005 01/01/2002 02/01/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/15/2003 03/01/2004 05/08/2009 05/01/2003 05/01/2003 05/01/2003 03/01/2004 05/05/2007 03/01/2004 05/05/2007 03/01/2004 05/05/2007 01/01/2002 01/01/2002 01/13/2003 06/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2007 12/31/2078 09/30/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 00517072001 BETAMETHASONE ACE/BETAMETH NA PHOS, PER 3MG 35356008401 INJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIU 04/28/2010 02/08/2008 12/31/2078 12/31/2078 J0702 J0702 40042004805 BETAMETHASONE ACE/BETAMETH NA PHOS, PER 3MG 54868020600 INJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIU 01/01/1990 01/01/2002 12/31/2011 12/31/2078 J0702 58016919101 INJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIU 01/01/2002 12/31/2078 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 00087601142 00406064602 00517002010 00574082301 00574082381 10106164901 10106164904 17317007301 17317007304 17317007305 17317007308 38779107305 38779107308 01/01/2004 01/01/2002 09/10/2007 09/21/2006 09/28/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/28/2002 01/28/2002 12/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 HCPCS NDC J0697 J0697 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0698 J0702 66860003103 66860003202 00039001710 00039001810 00039001811 00039001825 00039001849 00039001850 00039001910 00039001911 00039001925 00039001949 00039001950 00039002001 00039002049 00039002325 00039002349 00039002350 00039002361 00039002425 00039002449 00039002450 10019068001 10019068015 10019068102 10019068115 10019068203 10019068215 54569248400 54868342900 54868342901 63323033115 63323033215 63323033361 63323033461 63323033510 64679098601 64679098602 64679098603 64679098604 66860004203 66860004303 66860004401 00085056605 J0702 J0702 12/19/2013 HCPCS Description INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, CEFOTAXIME SODIUM, PER GM CEFOTAXIME INJ, PER GM CEFOTAXIME INJ, PER GM CEFOTAXIME INJ, PER GM INJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIU INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CAFFEINE CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, CITRATE, 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 06/01/2002 01/01/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/01/2005 01/01/2002 01/01/2002 06/01/2005 01/01/2002 06/01/2005 01/01/2002 04/03/2006 01/01/2002 06/01/2005 01/01/2002 07/05/2005 05/05/2007 07/05/2005 05/05/2007 07/05/2005 05/05/2007 01/01/2002 01/01/2002 01/01/2002 01/29/2002 01/29/2002 01/29/2002 01/29/2002 01/29/2002 09/20/2006 09/20/2006 09/20/2006 09/20/2006 10/01/2009 10/01/2009 10/01/2009 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2010 12/31/2011 12/31/2011 10/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0706 J0712 J0712 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0713 J0715 J0715 J0716 J0718 J0718 J0718 J0720 J0725 J0725 J0725 J0725 J0725 J0725 J0725 J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0735 49452133001 49452133002 49452133003 51552017805 51552017806 51927120200 62991150901 62991150902 63323040703 00456040010 00456060010 00074508216 00074508411 00074508611 00074509216 00173037710 00173037810 00173037934 00173038032 00173038237 00173043400 00173043500 00409508216 00409508252 00409508411 00409508451 00409508611 00409508651 00409509216 00409509252 00409509311 00409509351 00781317796 00781317895 00781317986 10019069102 10019069127 10019069203 10019069250 10019069304 10019069311 62991270301 00469722001 00469722102 66621015001 50474070062 50474071079 50474071081 63323001115 00052031510 52637012610 54569266000 54868412100 54868499700 55566150101 63323002510 38779056101 38779056103 38779056104 38779056106 49452214702 49452214703 49452214704 51552048001 51552048002 12/19/2013 HCPCS Description INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CEFTAROLINE FOSAMIL, 10 MG INJECTION, CEFTAROLINE FOSAMIL, 10 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTIZOXIME SODIUM, PER 500 MG INJECTION, CEFTIZOXIME SODIUM, PER 500 MG INJ, CENTRURIODES IMMUNE FAB, UP TO 120MG INJECTION, CERTOLIZUMAB PEGOL, 1 MG INJECTION, CERTOLIZUMAB PEGOL, 1 MG INJECTION, CERTOLIZUMAB PEGOL, 1 MG INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 12/04/2003 09/15/2003 09/15/2003 08/03/2007 01/26/2011 01/26/2011 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/01/2005 02/01/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/24/2005 10/04/2005 12/05/2005 10/04/2005 04/19/2006 10/04/2005 05/02/2006 06/27/2006 04/03/2006 10/01/2006 02/23/2007 02/23/2007 02/23/2007 03/22/2007 05/05/2007 03/22/2007 05/05/2007 03/22/2007 05/05/2007 01/01/2008 01/01/2002 01/01/2002 09/12/2011 05/13/2009 05/13/2009 05/13/2009 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/13/2007 02/18/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/03/2002 01/01/2002 01/01/2002 01/01/2002 11/15/2004 01/01/2002 09/01/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/01/2007 06/01/2007 09/01/2007 06/01/2007 12/31/2078 12/31/2078 12/31/2078 02/28/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0735 J0740 J0740 J0743 J0743 J0743 J0743 J0743 J0743 J0743 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0744 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 J0745 51927237900 62991142201 62991142202 63275997401 63275997402 63275997403 63370005210 63370005215 63370005225 66479052001 66479052101 67457021810 54868397900 61958010101 00006351458 00006351659 00006351775 00006355158 00006355259 00006358275 00006366659 00085173101 00085174102 00085175502 00085176201 00085176303 00085178101 00338096037 00338096048 00409476586 00409477702 00409477723 00409477761 00409477762 00409477886 00703095601 00703095603 00703095803 00703096036 00703096936 00781323909 00781324009 54868454700 55390019701 55390019801 55390019901 00406154832 00406154835 00409109732 00409110232 38779067903 38779067904 38779067905 49452002702 49452002703 49452002704 51552068802 51552068803 51552068804 51552068806 51927101300 63275810003 63275810004 63275810005 63304074801 12/19/2013 Earliest Start Date HCPCS Description INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG CLONIDINE, PER 1 MG INJECTION, CIDOFOVIR, 375 MG INJECTION, CIDOFOVIR, 375 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, CIPROFLOXACIN 200MG IV INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG 200 200 200 200 200 200 200 200 200 200 200 200 200 200 MG MG MG MG MG MG MG MG MG MG MG MG MG MG 200 200 200 200 200 200 200 200 200 200 MG MG MG MG MG MG MG MG MG MG 09/08/2003 09/15/2003 09/15/2003 01/01/2003 01/01/2003 01/01/2003 07/08/2003 07/08/2003 07/08/2003 06/28/2006 06/14/2006 02/01/2011 04/12/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/17/2005 08/17/2005 08/17/2005 08/17/2005 08/17/2005 08/17/2005 03/18/2008 03/18/2008 08/29/2006 03/19/2008 03/19/2008 05/19/2008 05/19/2008 08/29/2006 01/01/2007 08/28/2006 08/28/2006 03/18/2008 03/18/2008 03/18/2008 03/18/2008 01/01/2002 08/28/2006 08/28/2006 11/06/2006 01/01/2002 01/01/2002 11/15/2005 10/05/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 12/03/2002 12/03/2002 12/03/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2012 07/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2009 12/31/2078 12/31/2078 12/31/2078 04/30/2009 04/30/2009 11/14/2012 11/14/2012 05/31/2010 12/31/2078 06/30/2010 07/31/2011 05/31/2011 12/31/2078 12/31/2078 12/31/2078 04/01/2012 08/01/2011 12/31/2078 12/31/2078 03/31/2012 03/31/2012 03/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 60574310101 INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMA 01/01/2002 12/14/2009 15054050001 15054053006 67919001101 54868542800 54868542900 54868586700 55513000201 55513000204 55513000301 55513000304 55513000401 55513000404 55513000501 55513000504 55513000601 55513001001 55513001004 55513001101 55513001104 55513001201 55513001204 55513001301 55513001304 01/01/2012 01/01/2012 01/01/2005 08/10/2007 03/20/2008 03/20/2008 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2009 03/31/2009 11/30/2008 11/30/2008 12/31/2008 12/31/2008 04/30/2009 04/30/2009 HCPCS NDC J0745 J0745 J0745 J0745 J0760 J0760 J0760 J0760 J0760 J0770 J0770 J0770 J0770 J0770 J0770 J0770 J0770 J0770 J0775 J0780 J0780 J0780 J0780 J0780 J0780 J0780 J0780 J0780 J0780 J0780 J0780 J0780 J0795 J0800 J0835 J0835 J0835 J0840 J0850 63304074901 63370091015 63370091025 63370091035 49452221002 49452221003 51552099101 51927189500 55390060502 00574085801 00591355911 38779120303 38779120306 39822061501 51927210100 54868561200 61570041451 63323039306 66887000301 00641049121 00641049125 00703717104 00703717501 10019004301 10019004344 38779216503 38779216506 51927220600 54868026100 54868413700 55390007701 55390007710 55566030201 63004773101 00548590000 00781305271 00781305295 00281033010 44206310101 J0850 J0856 J0856 J0878 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, CODEINE PHOSPHATE, PER 30 MG CODEINE PHOSPHATE, PER 30 MG CODEINE PHOSPHATE, PER 30 MG CODEINE PHOSPHATE, PER 30 MG COLCHICINE, PER 1MG COLCHICINE, PER 1MG COLCHICINE, PER 1MG COLCHICINE, PER 1MG COLCHICINE, PER 1MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLISTIMETHATE SODIUM, UP TO 150 MG COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE, UP TO 10 MG CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAM CORTICOTROPIN, UP TO 40 UNITS COSYNTROPIN, PER 0.25 MG COSYNTROPIN, PER 0.25 MG COSYNTROPIN, PER 0.25 MG CROTALIDAE POLYVALENT IMMUNE FAB (OVINE), UP TO 1 CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMA ABOBOTULINUMTOXINA, 5 UNITS ABOBOTULINUMTOXINA, 5 UNITS DAPTOMYCIN, 1 MG DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) 01/01/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 09/01/2003 09/08/2003 01/01/2002 03/11/2005 01/30/2007 02/07/2002 02/07/2002 01/01/2002 09/08/2003 06/12/2006 01/01/2002 03/10/2008 03/31/2010 12/08/2004 01/01/2002 06/17/2003 06/17/2003 01/14/2005 05/05/2007 04/25/2002 04/25/2002 09/08/2003 01/01/2002 01/01/2002 07/22/2004 07/22/2004 01/01/2006 01/01/2002 06/26/2003 03/26/2008 03/26/2008 01/01/2012 02/20/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2009 12/31/2078 10/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2009 12/31/2078 12/31/2078 07/28/2010 07/28/2010 12/31/2078 12/31/2078 11/28/2008 11/28/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2013 12/31/2078 Page 1 of 1 HCPCS NDC J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0881 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 55513001401 55513001404 55513001501 55513002101 55513002104 55513002301 55513002304 55513002501 55513002504 55513002701 55513002704 55513002801 55513003201 55513003701 55513003704 55513003901 55513003904 55513004101 55513004104 55513004301 55513004304 55513004401 55513004601 55513004801 55513005301 55513005304 55513005401 55513005404 55513005701 55513005704 55513005801 55513005804 55513009001 55513009101 55513009201 55513009301 55513009401 55513009501 55513009601 55513009701 55513011001 55513011101 55513000201 55513000204 55513000301 55513000304 55513000401 55513000404 55513000501 55513000504 55513000601 55513001001 55513001004 55513001101 55513001104 55513001201 55513001204 55513001301 55513001304 55513001401 55513001404 55513001501 55513002101 55513002104 55513002301 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN DARBEPOETIN ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, ALFA, 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM MICROGRAM (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (NON-ESRD (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) (DIALYSIS) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) USE) Earliest Start Date 01/01/2006 02/08/2008 01/01/2006 08/14/2006 08/14/2006 08/14/2006 08/14/2006 08/14/2006 08/14/2006 09/11/2006 09/11/2006 08/14/2006 06/07/2006 02/08/2008 02/08/2008 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 09/11/2006 09/11/2006 02/08/2008 02/08/2008 08/14/2006 08/14/2006 01/01/2006 01/01/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 08/14/2006 08/14/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 09/11/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 08/14/2006 08/14/2006 08/14/2006 Latest End Date 02/28/2009 11/30/2007 04/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2008 11/30/2008 02/28/2009 02/28/2009 02/28/2009 02/28/2009 12/31/2008 12/31/2008 02/28/2009 04/30/2009 02/28/2009 12/31/2078 12/31/2078 12/31/2008 12/31/2008 12/31/2078 12/31/2078 03/31/2009 03/31/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2009 03/31/2009 11/30/2008 11/30/2008 12/31/2008 12/31/2008 04/30/2009 04/30/2009 02/28/2009 11/30/2007 04/30/2009 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0882 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 J0885 55513002304 55513002501 55513002504 55513002701 55513002704 55513002801 55513003201 55513003701 55513003704 55513003901 55513003904 55513004101 55513004104 55513004301 55513004304 55513004401 55513004601 55513004801 55513005301 55513005304 55513005401 55513005404 55513005701 55513005704 55513005801 55513005804 55513009001 55513009101 55513009201 55513009301 55513009401 55513009501 55513009601 55513009701 55513011001 55513011101 54868252300 54868252301 54868567301 54868580200 55513012601 55513012610 55513014401 55513014410 55513014801 55513014810 55513026701 55513026710 55513028301 55513028310 55513047801 55513047810 55513082301 55513082310 59676030201 59676030202 59676030301 59676030302 59676030401 59676030402 59676031001 59676031002 59676031201 59676031204 59676032001 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) DARBEPOETIN ALFA, 1 MICROGRAM (DIALYSIS) EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS Earliest Start Date 08/14/2006 08/14/2006 08/14/2006 09/11/2006 09/11/2006 08/14/2006 06/07/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 09/11/2006 09/11/2006 01/01/2006 01/01/2006 08/14/2006 08/14/2006 01/01/2006 01/01/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 09/25/2006 08/14/2006 08/14/2006 01/01/2006 01/01/2006 03/24/2008 08/13/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/18/2008 01/01/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2008 11/30/2008 02/28/2009 02/28/2009 02/28/2009 02/28/2009 12/31/2008 12/31/2008 02/28/2009 04/30/2009 02/28/2009 12/31/2078 12/31/2078 12/31/2008 12/31/2008 12/31/2078 12/31/2078 03/31/2009 03/31/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 02/28/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2010 07/31/2010 12/31/2078 07/01/2013 12/31/2078 09/01/2013 12/31/2078 09/01/2013 12/31/2078 12/31/2078 10/31/2009 12/31/2078 12/31/2009 Page 1 of 1 HCPCS NDC J0885 J0885 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0886 J0890 J0890 J0894 J0895 J0895 J0895 J0895 J0895 J0895 J0895 J0895 J0895 J0895 J0895 J0895 J0895 J0897 J0897 J0945 J0945 J0945 J0945 J0945 J0945 J0945 J0970 J0970 J0970 J0970 J0970 J0970 J0970 J0970 J0970 J0970 J0970 59676032004 59676034001 54868252300 54868252301 55513012601 55513012610 55513014401 55513014410 55513014801 55513014810 55513026701 55513026710 55513028301 55513028310 55513047801 55513047810 55513082301 55513082310 59676030201 59676030202 59676030301 59676030302 59676030401 59676030402 59676031001 59676031002 59676031204 59676032004 59676034001 64764061010 64764062020 62856060001 00078034751 00078046761 00078046791 00083380104 00409233610 00409233725 00555113111 00555113212 00703846309 00703846501 55390026310 55390026501 63323059710 55513071001 55513073001 49452130901 49452130904 49452130905 51552089402 51552089404 51552089405 51927195000 00781303175 38779056803 38779056804 38779056806 42023011201 49452279101 49452279102 49452279103 51552088801 51552088802 51552088804 12/19/2013 HCPCS Description INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 1000 UNITS INJECTION, PEGINESATIDE, 0.1 MG (FOR ESRD ON DIALYSIS) INJECTION, PEGINESATIDE, 0.1 MG (FOR ESRD ON DIALYSIS) DECITABINE INJ, PER 1 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, DENOSUMAB, 1 MG INJECTION, DENOSUMAB, 1 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG Earliest Start Date 07/01/2003 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2013 01/01/2013 12/15/2009 01/01/2002 01/05/2012 05/01/2007 01/01/2002 04/25/2005 03/21/2005 09/05/2007 09/05/2007 03/31/2006 03/31/2006 06/18/2007 06/18/2007 12/21/2009 01/01/2012 01/01/2012 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 10/04/2007 01/01/2002 01/01/2002 01/01/2002 03/31/2008 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2010 07/31/2010 12/31/2078 07/01/2013 12/31/2078 09/01/2013 12/31/2078 09/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2013 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2014 03/31/2014 03/31/2010 08/31/2009 12/31/2078 07/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J0970 J0970 J0970 J0970 J0970 J0970 J0970 J0970 J0970 J1000 J1000 J1000 J1000 J1000 J1000 J1000 J1000 J1000 J1000 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1020 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 51927169800 61570018101 61570018201 62991166202 62991166203 62991166204 63370008610 63370008615 63370008625 00009027101 38779190103 38779190104 38779190105 51927316300 54569258000 54868172900 63370008410 63370008415 63370008425 00009027401 00009028002 00009028003 00009028051 00009028052 00009030602 00009030612 00009307301 00009307303 00009347501 00009347503 00703003101 00703003104 00703004301 00703004501 00703005101 00703005104 00703006301 00009027401 00009028002 00009028003 00009028051 00009028052 00009030602 00009030612 00009307301 00009307303 00009347501 00009347503 00703003101 00703003104 00703004301 00703004501 00703005101 00703005104 00703006301 00781313171 12280025601 12280025605 35356008301 38779014403 38779014404 38779014405 38779014406 49452468801 49452468802 12/19/2013 HCPCS Description INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 20MG METHYLPREDNISOLONE ACETATE, PER 40MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG METHYLPREDNISOLONE ACETATE, PER 40MG METHYLPREDNISOLONE ACETATE, PER 40MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG METHYLPREDNISOLONE ACETATE, PER 40MG METHYLPREDNISOLONE ACETATE, PER 40MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG METHYLPREDNISOLONE ACETATE, PER 40MG METHYLPREDNISOLONE ACETATE, PER 40MG METHYLPREDNISOLONE ACETATE, PER 40MG METHYLPREDNISOLONE ACETATE, PER 40MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG Earliest Start Date 09/08/2003 10/24/2002 10/24/2002 11/01/2005 11/01/2005 11/01/2005 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/08/2003 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2006 01/01/2006 01/01/2002 01/01/2002 01/01/2006 01/01/2006 03/09/2005 03/09/2005 10/31/2006 10/31/2006 01/01/2006 01/01/2006 01/01/2006 04/21/2009 05/19/2006 12/14/2005 02/08/2008 01/01/2002 01/01/2002 09/03/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 07/31/2008 03/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1030 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1040 J1050 J1050 J1050 J1050 J1050 J1050 J1050 J1050 J1050 J1051 J1051 J1051 J1051 J1051 J1051 J1051 J1051 J1051 J1051 J1051 49452468803 51552095802 51552095804 51552095805 51552095806 51927133200 54569190101 54569394600 54569426500 54868389600 54868389601 54868389602 55045324202 55045324205 62991163502 62991163503 62991163504 62991163505 62991163506 63370013810 63370013815 63370013825 63370013835 63370013850 00009027401 00009028002 00009028003 00009028051 00009028052 00009030602 00009030612 00009307301 00009307303 00009347501 00009347503 00703003101 00703003104 00703004301 00703004501 00703005101 00703005104 00703006301 35356017805 55045324301 58016489301 00009062601 00009074630 00009074635 00009737607 00009737611 00703680101 00703680104 59762453701 59762453802 00009062601 00009062602 00009062603 00009074630 00009074631 00009074634 00009074635 00009470901 00009737601 00009737602 00009737603 12/19/2013 HCPCS Description INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG METHYLPREDNISOLONE 80MG INJ METHYLPREDNISOLONE 80MG INJ METHYLPREDNISOLONE 80MG INJ METHYLPREDNISOLONE 80MG INJ METHYLPREDNISOLONE 80MG INJ METHYLPREDNISOLONE 80MG INJ METHYLPREDNISOLONE ACETATE, PER 80MG METHYLPREDNISOLONE 80MG INJ METHYLPREDNISOLONE 80MG INJ INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG MEDROXYPROGESTERONE INJ ACETATE, PER 1 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG Earliest Start Date 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/03/2005 02/02/2007 07/01/2006 07/01/2006 09/01/2002 09/01/2002 09/15/2003 09/15/2003 09/15/2003 10/25/2006 10/25/2006 10/25/2006 10/25/2006 10/25/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 03/09/2005 03/09/2005 10/31/2006 05/16/2008 07/20/2006 06/01/2006 09/30/1990 12/01/1992 12/01/1992 04/08/1996 04/08/1996 09/14/2004 09/14/2004 12/01/1992 04/08/1996 01/01/2003 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 04/06/2005 01/01/2006 01/01/2006 01/01/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/01/2003 12/31/2078 12/31/2078 03/31/1998 02/28/1999 12/31/2078 04/30/2012 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 00009074631 MEDROXYPROGESTERONE INJ ACETATE, PER 150 MG (CONTRACEPTIVE) 00009074634 MEDROXYPROGESTERONE INJ ACETATE, PER 150 MG (CONTRACEPTIVE) 00009074635 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 01/01/2006 01/01/2006 01/01/2002 03/31/1998 02/28/1999 12/31/2078 J1055 J1055 00009470901 MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150MG 00009737604 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 01/01/2006 04/21/2003 04/30/2012 04/30/2013 J1055 00703680101 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 09/13/2004 12/31/2078 J1055 00703680104 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 09/13/2004 12/31/2078 J1055 00703681121 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 09/16/2005 04/30/2012 J1055 23490585401 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 02/07/2007 12/31/2078 J1055 54569370100 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 01/01/2002 12/31/2078 J1055 54569490400 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 01/01/2002 12/31/2078 J1055 54569552700 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 08/15/2003 12/31/2078 J1055 54868361300 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 01/01/2002 12/31/2078 J1055 54868410000 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 01/01/2002 12/31/2078 J1055 54868410001 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 02/11/2002 12/31/2078 J1055 54868525700 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 03/30/2005 12/31/2078 J1055 55045350501 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 06/28/2006 12/31/2078 J1055 59762453701 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 09/27/2004 12/31/2078 J1055 59762453702 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 09/27/2004 12/31/2078 J1055 59762453801 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 05/26/2006 11/30/2013 J1055 59762453809 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE 04/01/2008 12/31/2078 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 00009034702 00009041702 00574082010 00781307370 35356005810 38779016403 38779016404 38779016405 38779016408 38779016409 49452766001 49452766002 49452766003 51927270600 01/01/2002 01/01/2006 12/29/2007 10/17/2006 11/09/2007 01/01/2002 01/01/2002 01/01/2002 04/30/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/08/2003 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 HCPCS NDC J1051 J1051 J1051 J1051 J1051 J1051 J1051 J1051 J1055 J1055 J1055 J1055 00009737604 00703680101 00703680104 00703681121 54868334801 59762453701 59762453702 59762453801 00009062601 00009062602 00009062603 00009074630 J1055 J1055 J1055 12/19/2013 HCPCS Description MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 50 MG MEDROXYPROGESTERONE INJ ACETATE, PER 150 MG (CONTRACEPTIVE) MEDROXYPROGESTERONE INJ ACETATE, PER 150 MG (CONTRACEPTIVE) MEDROXYPROGESTERONE INJ ACETATE, PER 150 MG (CONTRACEPTIVE) INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE INJECTION, TESTOSTERONE CYPIONATE, UP TESTOSTERONE CYPIONATE UP TO 100MG TESTOSTERONE CYPIONATE UP TO 100MG INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG TO TO TO TO TO TO TO TO TO TO TO 100 100 100 100 100 100 100 100 100 100 100 MG MG MG MG MG MG MG MG MG MG MG 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2003 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2002 04/30/2013 12/31/2078 12/31/2078 04/30/2012 12/31/2078 12/31/2078 12/31/2078 11/30/2013 12/31/2078 05/01/2003 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1070 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1080 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1094 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 J1100 54868079600 62991170701 62991170702 62991170703 62991170705 63275998204 63275998205 63275998209 63370098025 63370098035 63370098050 00009034702 00009041701 00009041702 00574082001 00574082010 00591322379 00703612101 00703612501 00781307470 00781307471 23490634301 54569141100 54868021600 54868361800 54868361801 55045302902 63874106101 25332001105 38779190501 38779190503 38779190504 38779190505 49452246001 49452246002 49452246003 51552002401 51552002402 51552002403 51552002404 51927223100 51927374700 55553009205 63370006015 63370006020 63370006025 63370006035 63370006050 00069454702 00517490125 00517490525 00517493025 00641036721 00703352401 00703352403 23490541300 49999043425 54569464800 54868087100 54868087101 54868087106 55045321203 55553066110 55553080705 63323016501 12/19/2013 HCPCS Description INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG TESTOSTERONE CYPIOANTE INJ, 200MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG DEXAMETH NA PHOS 4MG/ML INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJ, DEXAMETHASONE NA PHOS, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG Earliest Start Date 10/21/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/04/2002 12/04/2002 12/04/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2006 01/01/2002 01/01/2002 12/21/2007 12/21/2007 03/29/2004 04/16/2007 04/16/2007 10/17/2006 10/17/2006 02/07/2007 01/01/2002 09/20/2007 01/01/2002 08/10/2007 01/01/2003 01/01/2008 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 03/11/2005 01/01/2003 07/08/2003 01/01/2003 07/08/2003 07/08/2003 07/08/2003 07/19/2011 01/01/2002 01/01/2002 01/01/2002 12/08/2004 01/01/2007 02/20/2002 04/09/2007 04/25/2008 01/01/2002 01/01/2002 07/21/2003 01/01/2002 07/01/2006 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2011 12/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2011 03/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1100 J1100 J1100 J1100 J1110 J1110 J1110 J1110 J1110 J1110 J1110 J1110 J1110 J1110 J1110 J1110 J1120 J1160 J1160 J1160 J1160 J1160 J1160 J1160 J1160 J1160 J1160 J1160 J1162 J1162 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1165 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 63323016505 63323016530 63323050601 63323051610 00574085005 00574085010 38779030303 38779030306 49452261601 49452261602 49452261603 51552023301 51552023302 51927170600 55390001310 66490004101 55390046001 00173026010 00173026035 00173026210 00409216931 00641141031 00781305995 38779021500 38779021506 38779021509 49452261202 51927174600 00173023044 00281036510 00143988125 00143988225 00409131701 00409131702 00409184432 00641049321 00641255541 00703710104 00703710503 38779021604 38779021605 38779021608 49452534401 49452534402 49452534403 51552053204 51927183800 60505074605 60505076504 62991125401 62991125402 62991125403 63370017625 63370017635 63370017645 63370017653 00074128301 00074233211 00074233311 00074233326 00074233411 00074241421 00074242816 00074245311 00074245327 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE SODIUM PHOSPHATE, 1MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG DIHYDROERGOTAMINE MESYLATE, PER 1 MG ACETAZOLAMIDE SODIUM, UP TO 500 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN, UP TO 0.5 MG DIGOXIN IMMUNE FAB (OVINE), PER VIAL DIGOXIN IMMUNE FAB (OVINE), PER VIAL PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG PHENYTOIN SODIUM, PER 50 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG Earliest Start Date 01/01/2002 01/01/2002 05/30/2003 08/23/2005 08/04/2003 03/15/2004 01/01/2002 01/01/2002 01/31/2002 01/31/2002 01/31/2002 01/01/2002 09/01/2003 09/08/2003 09/03/2003 12/31/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/16/2005 05/05/2007 07/21/2006 02/05/2002 02/05/2002 02/05/2002 01/01/2002 09/08/2003 01/01/2006 01/01/2006 04/03/2007 04/03/2007 02/08/2005 03/30/2005 10/05/2004 12/08/2004 05/05/2007 09/14/2007 09/14/2007 01/01/2002 01/01/2002 01/01/2002 03/07/2002 03/07/2002 03/07/2002 09/01/2003 09/08/2003 10/24/2007 10/24/2007 09/15/2003 09/15/2003 09/15/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2002 11/05/2002 11/14/2002 12/11/2002 12/19/2002 12/19/2002 02/10/2003 12/19/2002 11/14/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2013 08/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2011 04/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/01/2003 05/01/2011 05/01/2011 03/01/2011 04/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 00074245351 00074245531 00406324552 00409128305 00409128310 00409128331 00409130431 00409131210 00409131230 00409217201 00409217205 00409254001 00409255201 00409335601 00409336501 00555111705 00555111706 00555111707 00574201701 00641012121 00641012125 00641234139 00641234141 38779073101 38779073103 38779073104 38779073105 38779073106 49452002901 49452002902 49452002903 49452002904 51552068201 51552068202 51552068203 51552068204 51927100300 54868513700 54868531900 58298053402 58298053403 59011044110 59011044225 59011044410 59011044505 61553016141 61553016267 61553016375 61553016541 61553016667 61553016775 61553062448 61553068176 61553070168 61553070268 61553070468 61553070568 61553070668 61553071068 61553071268 61553078068 61703024345 61703024350 61703024353 61703024615 12/19/2013 HCPCS Description INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, HYDROMORPHONE INJ, 4 MG HYDROMORPHONE INJ, 4 MG INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, INJECTION, HYDROMORPHONE, UP TO UP TO UP TO UP TO UP TO UP TO 4MG UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO UP TO 4MG 4MG 4 4 4 4 4 4 MG MG MG MG MG MG 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO Earliest Start Date 11/26/2002 12/11/2002 01/01/2002 10/22/2012 05/15/2009 06/14/2005 07/01/1997 10/01/2010 07/07/2005 04/19/2005 04/19/2005 09/21/2005 09/21/2005 09/21/2005 09/21/2005 05/08/2007 05/08/2007 05/08/2007 01/01/2002 12/08/2004 01/01/2002 05/05/2007 01/01/2002 04/23/2002 01/01/2002 01/01/2002 09/27/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/15/2004 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 08/13/2004 05/31/2005 04/03/2006 04/03/2006 01/01/2009 01/01/2009 09/30/1990 02/18/2009 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 11/21/2007 12/01/2006 12/01/2006 12/01/2006 12/01/2006 12/01/2006 12/01/2006 12/01/2006 12/01/2006 05/15/2003 05/15/2003 05/15/2003 10/08/2003 Latest End Date 12/31/2078 07/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2011 10/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2011 09/30/2011 06/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1170 J1180 J1190 J1190 J1190 J1190 J1190 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1200 J1205 J1212 J1212 J1212 J1212 J1212 J1212 J1212 61703042594 61703042595 63275200101 63275200502 63275201003 63275210005 63275210009 63370093010 63370093015 63370093020 63370093025 63370093035 51927165900 00013871562 00013872589 38423011001 55390001402 55390006002 00071425945 00409229011 00409229031 00463108030 00463108910 00548139000 00641037621 12280022710 17317014603 17317014605 17317014606 38779028204 38779028205 38779028208 38779028209 49452264001 49452264002 49999052510 51552012402 51552012404 51552012405 51552012406 51927107900 54569581500 54868000700 54868055400 54868204800 54868204801 54868305300 54868364400 55045329801 55553082710 62991104702 63323066401 63370007125 63370007135 63370007145 63370007150 67457012410 67386071155 00433043305 10106922401 17317082801 49452258801 49452258802 49452258804 51552105306 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE, UP TO 4 MG DYPHYLLINE, UP TO 500 MG DEXRAZOXANE HYDROCHLORIDE, PER 250 MG DEXRAZOXANE HYDROCHLORIDE, PER 250 MG DEXRAZOXANE HYDROCHLORIDE, PER 250 MG DEXRAZOXANE HYDROCHLORIDE, PER 250 MG DEXRAZOXANE HYDROCHLORIDE, PER 250 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG DIPHENHYDRAMINE HCL, UP TO 50 MG CHLOROTHIAZIDE SODIUM, PER 500 MG DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML Earliest Start Date 03/07/2006 03/07/2006 12/03/2002 12/03/2002 12/03/2002 12/03/2002 09/01/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 09/08/2003 01/01/2002 01/01/2002 09/06/2007 04/08/2005 04/08/2005 01/01/2002 07/31/2008 04/25/2005 01/01/2002 01/01/2002 01/01/2002 12/08/2004 08/08/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/22/2002 01/01/2002 01/01/2002 01/25/2008 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 08/03/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/13/2006 01/01/2002 01/01/2005 01/01/2002 01/01/2002 06/12/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 05/01/2007 01/21/2006 01/01/2002 01/01/2002 01/01/2002 01/31/2002 01/31/2002 01/31/2002 09/01/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1212 J1212 J1212 J1212 J1212 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1230 J1240 J1240 J1240 J1240 J1240 J1240 J1240 J1240 J1245 J1245 J1245 J1245 J1245 J1245 J1245 J1245 J1245 J1245 J1245 J1245 J1245 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 J1250 51927161200 51927328700 62991153601 62991153602 67457017750 00406151056 00406151057 00406151059 38779010403 38779010404 38779010405 49452455301 49452455302 49452455303 51552072801 51552072802 51552072804 51927101700 63275910004 63275910005 63370093915 63370093925 63370093935 64019075085 64019075088 66479053002 66591081551 66689068155 00463108610 38779028104 38779028105 38779028108 51552067604 51552067605 51927108000 63323036601 00409204302 00641256941 00703165202 00703165401 00703165402 49452264103 49452264104 49452264105 51927157100 55390055510 55390055590 60505071500 60505071501 00074472901 00338107302 00338107303 00338107502 00338107702 00409202520 00409202554 00409234401 00409234402 00409234488 00409234632 00409234634 00409234732 00409234733 00409372432 51927277500 12/19/2013 HCPCS Description INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 10MG IV INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG Earliest Start Date 12/04/2003 12/04/2003 09/15/2003 09/15/2003 06/22/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/31/2002 01/31/2002 11/15/2004 09/01/2003 09/01/2003 09/01/2004 09/08/2003 12/03/2002 12/03/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 01/09/2007 12/12/2003 02/01/2002 01/01/2002 02/05/2002 02/05/2002 02/05/2002 09/01/2003 09/01/2003 09/08/2003 07/01/2004 03/31/2005 05/05/2007 01/01/2002 01/01/2007 01/01/2002 01/01/2003 01/01/2003 01/01/2003 09/08/2003 01/01/2002 04/08/2005 08/01/2004 08/01/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/20/2006 11/10/2005 07/27/2005 06/29/2005 03/21/2005 08/11/2005 02/07/2006 01/11/2006 03/21/2005 10/07/2005 09/08/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2010 12/31/2078 12/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1250 J1250 J1250 J1250 J1260 J1260 J1260 J1260 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1265 J1267 J1267 J1270 J1270 J1270 J1290 J1300 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1320 J1324 J1324 J1324 54868571700 54868571701 54868571702 55390056090 00088120632 00088120806 00088120876 00088120926 00074414103 00074414203 00264144155 00264144255 00264148155 00264148255 00264149255 00338100502 00338100503 00338100702 00338100703 00338100902 00409414202 00409426501 00409582001 00409780822 00409780824 00409780922 00409780924 00409781022 00409910420 00517130525 00517180525 00517190525 51927231900 54868001500 50458040102 50458040202 58468012201 58468012301 58468012601 47783010101 25682000101 38779018903 38779018904 38779018905 49452046001 49452046002 49452046003 51552046402 51552046404 51552046405 51552046406 51927160300 62991200401 62991200402 62991200403 63275993602 63275993604 63275993605 63275993608 63370001815 63370001825 63370001835 00004038039 35356020660 54569578100 12/19/2013 HCPCS Description INJECTION, DOBUTAMINE HYDROCHLORIDE, PER INJECTION, DOBUTAMINE HYDROCHLORIDE, PER INJECTION, DOBUTAMINE HYDROCHLORIDE, PER INJECTION, DOBUTAMINE HYDROCHLORIDE, PER INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, DORIPENEM, 10 MG INJECTION, DORIPENEM, 10 MG INJECTION, DOXERCALCIFEROL, 1 MCG INJECTION, DOXERCALCIFEROL, 1 MCG DOXERCALCIFEROL, PER 1 MCG INJECTION, ECALLANTIDE, 1 MG INJECTION, ECULIZUMAB, 10 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, ENFUVIRTIDE, 1 MG INJECTION, ENFUVIRTIDE, 1 MG INJECTION, ENFUVIRTIDE, 1 MG 250 250 250 250 MG MG MG MG Earliest Start Date 12/11/2006 01/02/2007 06/28/2007 01/01/2002 01/01/2002 12/15/2003 02/20/2002 07/21/2003 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 12/11/2006 01/01/2012 01/01/2012 06/01/2006 01/01/2009 01/10/2011 01/01/2012 01/01/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2007 01/01/2007 07/08/2003 07/08/2003 07/08/2003 01/01/2007 05/30/2008 01/01/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2014 09/30/2014 09/30/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2013 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1325 J1325 J1325 J1325 J1325 J1325 J1325 J1327 J1327 J1327 J1330 J1330 J1330 J1330 J1330 J1330 J1330 J1335 J1335 J1364 J1364 J1364 J1364 J1364 J1380 J1380 J1380 J1380 J1390 J1390 J1390 J1390 J1410 J1430 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1435 J1438 J1438 J1438 J1438 J1438 J1438 00173051700 00173051900 00703198501 00703199501 66215040101 66215040201 66215040301 00085113601 00085117701 00085117702 49452276202 49452276203 51552018801 51552018805 51552018807 51927209900 63704000201 00006384371 00006384571 00074647644 00074647844 00409647644 00409647844 00409648201 00781303075 42023011001 42023011101 61570018001 00781302975 42023011101 61570018101 61570018201 00046074905 67871479006 00463102930 38779089103 38779089104 38779089105 38779089106 49452279501 49452279502 49452279504 51552044501 51552044502 51552044504 51927170900 52637031310 55553004110 62991105101 62991105102 62991105103 62991105104 63275998601 63275998602 63275998604 63370009010 63370009015 63370009025 63370009035 54868478200 54868544400 58406042534 58406042541 58406043501 58406043504 12/19/2013 Earliest Start Date HCPCS Description INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPTIFIBATIDE, 5 MG INJECTION, EPTIFIBATIDE, 5 MG INJECTION, EPTIFIBATIDE, 5 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERTAPENEM SODIUM, 500 MG INJECTION, ERTAPENEM SODIUM, 500 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ESTRADIOL VALERATE, UP TO 10 MG INJECTION, ESTRADIOL VALERATE, UP TO 10 MG ESTRADIOL VALERATE INJ, UP TO 10MG INJECTION, ESTRADIOL VALERATE, UP TO 10 MG INJECTION, ESTRADIOL VALERATE, UP TO 20 MG INJECTION, ESTRADIOL VALERATE, UP TO 20 MG INJECTION, ESTRADIOL VALERATE, UP TO 20 MG ESTRADIOL VALERATE INJ, UP TO 20MG INJECTION, ESTROGEN CONJUGATED, PER 25 MG INJECTION, ETHANOLAMINE OLEATE, 100 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE MEDICARE MEDICARE MEDICARE MEDICARE MEDICARE 01/01/2002 01/01/2002 04/23/2008 04/23/2008 08/27/2007 10/01/2012 10/01/2012 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/08/2003 01/01/2006 01/01/2004 04/16/2007 01/01/2002 01/01/2002 03/10/2006 01/10/2007 05/23/2005 10/04/2007 12/10/2007 09/03/1990 10/24/2002 10/04/2007 12/18/2007 08/29/2002 01/01/2006 01/01/2002 01/01/2006 01/01/2002 01/01/2002 01/01/2002 08/21/2002 01/01/2002 01/01/2002 01/01/2002 11/15/2004 01/01/2002 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/15/2003 09/15/2003 12/04/2002 12/04/2002 12/04/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 04/30/2003 03/18/2008 01/01/2002 01/01/2002 11/17/2004 11/17/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/01/2008 11/01/2007 12/31/2078 10/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2008 12/31/2078 12/31/2078 07/31/2008 03/31/2009 12/31/2078 12/31/2078 12/17/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1438 J1438 J1438 J1438 J1440 J1440 J1440 J1440 J1440 J1440 J1441 J1441 J1441 J1441 J1441 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 J1450 58406044501 58406044504 58406045501 58406045504 54868252200 54868502000 55513053001 55513053010 55513092401 55513092410 54868305000 55513020901 55513020910 55513054601 55513054610 00049337126 00049337226 00049343526 00049343626 00049343726 00049343826 00074468402 00074468833 00143989906 00143989991 00338604537 00338604648 00409468402 00409468423 00409468802 00409468823 00409468827 00409468828 00409468833 00409468834 00703101009 00703101909 00703102030 00703102930 25021011382 25021011387 49452315101 49452315102 49452315103 51552103101 51552103102 51552103104 55390001201 55390004601 55390019401 59762503402 59762503502 59762503602 59762503702 60505073301 60505073302 60505073401 60505073402 61703041463 61703041464 63275996001 63275996002 63275996004 63275996005 63275996009 12/19/2013 HCPCS Description INJECTION, ETANERCEPT, 25 MG (CODE MAY INJECTION, ETANERCEPT, 25 MG (CODE MAY INJECTION, ETANERCEPT, 25 MG (CODE MAY INJECTION, ETANERCEPT, 25 MG (CODE MAY INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 480 MCG INJECTION, FILGRASTIM (G-CSF), 480 MCG INJECTION, FILGRASTIM (G-CSF), 480 MCG INJECTION, FILGRASTIM (G-CSF), 480 MCG INJECTION, FILGRASTIM (G-CSF), 480 MCG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG FLUCONAZOLE INJ PER 200MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG FLUCONAZOLE 200MG/100ML FLUCONAZOLE INJ PER 200MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG FLUCONAZOLE INJ PER 200MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG BE BE BE BE USED USED USED USED FOR FOR FOR FOR MEDICARE MEDICARE MEDICARE MEDICARE Earliest Start Date 07/17/2006 07/17/2006 04/30/2007 04/30/2007 01/01/2002 03/11/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/14/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/01/2006 04/01/2006 04/03/2007 07/14/2006 07/29/2004 07/29/2004 03/06/2007 04/14/2006 07/27/2006 06/16/2006 05/27/2006 06/01/2005 10/25/2006 03/02/2006 08/02/2004 08/02/2004 03/14/2005 03/16/2005 08/27/2009 08/27/2009 01/01/2003 01/01/2003 11/15/2004 09/01/2003 09/01/2003 09/01/2003 07/29/2004 07/29/2004 01/14/2010 09/09/2004 09/09/2004 09/09/2004 09/09/2004 05/25/2005 05/25/2005 05/25/2005 05/25/2005 06/09/2004 06/09/2004 05/01/2004 05/01/2004 05/01/2004 05/01/2004 05/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/01/2011 11/01/2014 07/31/2011 07/31/2011 05/31/2010 07/31/2011 08/01/2007 01/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/05/2013 09/05/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2007 11/30/2007 11/30/2007 11/30/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1450 J1450 J1450 J1450 J1450 J1450 J1451 J1451 J1451 J1451 J1451 J1453 J1453 J1455 J1455 J1455 J1457 J1457 J1458 J1459 J1459 J1459 J1459 J1460 J1460 J1460 J1460 J1460 J1460 J1470 J1470 J1470 J1470 J1470 J1470 J1470 J1470 J1480 J1480 J1480 J1480 J1480 J1480 J1480 J1480 J1490 J1490 J1490 J1490 J1490 J1490 J1490 J1490 J1500 J1500 J1500 J1500 J1500 J1500 J1500 J1500 J1510 J1510 J1510 J1510 63323030861 63323030863 63370008925 63370008935 63370008945 63370008950 00781318273 00781318284 39822071001 62161000334 68727020002 00006388432 00006394132 00186190601 00409386302 00409386305 51927325600 66657030105 68135002001 44206043605 44206043710 44206043820 44206043940 13533063503 13533063504 13533063512 54569527500 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 12/19/2013 Earliest Start Date HCPCS Description INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION FLUCONAZOLE, 200 MG INJECTION, FOMEPIZOLE, 15 MG INJECTION, FOMEPIZOLE, 15 MG INJECTION, FOMEPIZOLE, 15 MG INJECTION, FOMEPIZOLE, 15 MG INJECTION, FOMEPIZOLE, 15 MG INJECTION, FOSAPREPITANT, 1 MG FOSAPREPITANT, 1MG INJECTION, FOSCARNET SODIUM, PER 1000 MG INJECTION, FOSCARNET SODIUM, PER 1000 MG INJECTION, FOSCARNET SODIUM, PER 1000 MG INJECTION, GALLIUM NITRATE, 1 MG INJECTION, GALLIUM NITRATE, 1 MG INJECTION, GALSULFASE, 1 MG INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC NON-LYOP NON-LYOP NON-LYOP NON-LYOP 07/08/2004 07/08/2004 07/12/2004 07/12/2004 07/12/2004 07/12/2004 04/02/2008 04/02/2008 12/14/2007 01/01/2006 11/09/2006 01/30/2008 11/15/2010 01/01/2002 02/01/2006 02/01/2006 01/01/2005 01/01/2005 01/01/2007 01/01/2009 01/01/2009 01/01/2009 06/01/2013 01/17/2008 10/04/2005 10/04/2005 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2011 06/30/2012 07/31/2012 12/31/2078 04/30/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX-C/GAMMAKED), NON-LYOPHI (GAMUNEX/GAMUNEX-C/GAMMAKED), NO 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 01/01/2002 09/26/2006 01/01/2002 01/01/2002 01/01/2002 10/04/2005 10/04/2005 01/01/2002 09/26/2006 01/01/2002 01/01/2012 01/01/2012 01/01/2012 01/01/2011 01/01/2011 01/01/2011 01/01/2006 01/01/2006 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 12/07/2010 12/07/2010 12/07/2010 12/07/2010 12/07/2010 12/29/2010 Latest End Date J1561 76125090050 INJECTION, IMMUNE GLOBULIN, (GAMUNEX/GAMUNEX-C/GAMMAKED), NO 12/29/2010 12/31/2078 J1562 J1562 J1562 J1562 J1562 J1566 J1566 J1566 00053759603 00053759610 00053759615 00053759620 00053759625 00053748605 00053748610 00944047169 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2006 01/01/2006 01/01/2006 12/31/2078 05/06/2013 12/31/2078 06/08/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 HCPCS NDC J1510 J1510 J1510 J1510 J1520 J1520 J1520 J1520 J1520 J1520 J1520 J1520 J1530 J1530 J1530 J1530 J1530 J1530 J1530 J1530 J1540 J1540 J1540 J1540 J1540 J1540 J1540 J1540 J1550 J1550 J1550 J1550 J1550 J1550 J1550 J1557 J1557 J1557 J1559 J1559 J1559 J1560 J1560 J1561 J1561 J1561 J1561 J1561 J1561 J1561 J1561 J1561 J1561 J1561 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569527600 54569582800 54868419300 00026063504 00026063512 13533063504 13533063512 54569527500 54569582800 54868419300 64208823401 64208823402 64208823403 44206045101 44206045202 44206045404 13533063504 13533063512 13533064512 13533064515 13533064520 13533064524 13533064571 13533080012 13533080015 13533080020 13533080024 13533080071 76125090010 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, 10 CC 10 CC INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC IMMUNE GLOBULIN (GAMMAPLEX), INTRAVENOUS, NONLYOP IMMUNE GLOBULIN (GAMMAPLEX), INTRAVENOUS, NONLYOP IMMUNE GLOBULIN (GAMMAPLEX), INTRAVENOUS, NONLYOP IMMUNE GLOBULIN (HIZENTRA), 100 MG IMMUNE GLOBULIN (HIZENTRA), 100 MG IMMUNE GLOBULIN (HIZENTRA), 100 MG IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE IMMUNE GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN, GLOBULIN (VIVAGLOBIN), 100 MG GLOBULIN (VIVAGLOBIN), 100 MG GLOBULIN (VIVAGLOBIN), 100 MG GLOBULIN (VIVAGLOBIN), 100 MG GLOBULIN (VIVAGLOBIN), 100 MG GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/13/2006 03/06/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/24/2013 04/19/2013 06/26/2014 10/17/2013 10/22/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1566 J1567 J1567 J1567 J1567 J1567 J1567 J1568 J1568 J1568 J1568 J1568 J1568 J1568 J1568 J1568 J1569 J1569 J1569 J1569 J1569 J1569 J1570 J1571 J1571 J1572 J1572 J1572 J1572 J1572 J1572 J1572 J1572 J1572 J1573 J1573 J1573 J1573 J1573 J1573 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 00944047172 00944047175 00944047180 00944262001 00944262002 00944262003 00944262004 00944265503 00944265504 00944265603 00944265804 44206041501 44206041603 44206041706 44206041812 52769041706 52769041812 52769047072 68516161201 68516161301 68516161401 68516162201 68516162301 68516162401 67467084301 67467084302 67467084303 67467084304 67467084305 68209084301 68209084302 68209084303 68209084304 00944270002 00944270003 00944270004 00944270005 00944270006 00944270007 00004694003 60492005101 60492005201 61953000301 61953000302 61953000303 61953000304 61953000401 61953000402 61953000403 61953000404 61953000405 53270005101 53270005201 53270005301 53270005401 60492005102 60492005202 00264580632 00264580832 00264581032 00264581238 00264581638 00338050148 00338050348 00338050548 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOP IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILI IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILI IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILI IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILI IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILI IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILI GANCICLOVIR SODIUM, 500 MG HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUS HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUS IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVEN HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVEN HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVEN HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVEN HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVEN HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVEN GARAMYCIN, GENTAMICIN, UP TO 80 MG GARAMYCIN, GENTAMICIN, UP TO 80 MG GARAMYCIN, GENTAMICIN, UP TO 80 MG GARAMYCIN, GENTAMICIN, UP TO 80 MG GARAMYCIN, GENTAMICIN, UP TO 80 MG GARAMYCIN, GENTAMICIN, UP TO 80 MG GARAMYCIN, GENTAMICIN, UP TO 80 MG GARAMYCIN, GENTAMICIN, UP TO 80 MG Earliest Start Date 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 06/01/2007 06/01/2007 01/24/2013 01/24/2013 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 03/18/2011 01/01/2002 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 08/01/2010 08/01/2010 08/01/2010 08/01/2010 01/01/2008 01/01/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/25/2013 04/11/2014 06/21/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/03/2014 12/31/2078 12/31/2078 04/08/2009 03/27/2009 02/21/1994 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2013 04/30/2013 08/31/2012 04/30/2013 11/30/2010 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1580 J1595 J1595 J1595 J1599 J1599 J1599 J1600 J1600 J1600 J1600 J1600 J1610 J1610 J1610 J1610 J1610 J1610 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1626 J1630 J1630 J1630 J1630 J1630 00338050741 00338050748 00338050941 00338051141 00409120703 00409340001 00409340101 00409340201 00409787913 00409788113 00409788313 00409788423 00409788623 00409788923 54868410300 63323001002 63323001020 63323017302 63323051302 00088115330 68115075030 68546031730 64208823401 64208823402 64208823403 11098053301 11098053310 51927289500 54643100600 54643100700 00002803101 00169706515 54569473400 54868507000 55390000401 55390000410 00004023909 00004024009 00703787103 00703789102 00703797103 00703797301 10019005303 10019005314 17478054601 17478054605 25021078104 55390025010 60505069200 60505069300 60505076402 63323031701 63323031801 63323031904 64679066102 64679066103 64679066201 66758003501 66758003601 66758003702 00045025501 00703704103 00703704501 10147091101 25021080601 12/19/2013 HCPCS Description INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E. INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG GRANISETRON INJ PER 100 MCG GRANISETRON INJ PER 100 MCG GRANISETRON INJ PER 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LACTATE PER 5MG HALOPERIDOL INJ 5MG Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/30/2005 03/24/2006 01/09/2006 06/05/2006 03/31/2006 01/23/2006 01/09/2006 07/06/2005 01/27/2006 09/20/2005 02/12/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2004 03/29/2004 04/28/2008 01/01/2011 01/01/2011 01/01/2011 06/21/2002 06/21/2002 09/08/2003 10/01/2003 10/01/2003 01/01/2002 06/01/2005 01/01/2002 05/24/2004 01/01/2002 01/01/2002 01/03/2002 06/09/1997 01/03/2008 01/03/2008 01/03/2008 06/30/2008 12/31/2007 12/31/2007 03/01/2010 03/01/2010 01/03/2011 07/29/2008 08/14/2008 08/14/2008 12/31/2007 12/14/2007 06/25/2008 06/25/2008 07/01/2008 07/01/2008 04/25/2008 06/30/2008 06/30/2008 06/30/2008 01/01/2002 01/18/2002 01/18/2002 07/11/2011 12/02/2011 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2010 11/30/2011 08/31/2010 12/31/2010 12/31/2078 12/31/2078 06/28/2010 06/28/2010 03/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2011 10/31/2012 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1630 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1631 J1640 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 38779033001 38779033003 38779033004 38779033005 38779033006 49452344601 49452344602 50458025501 51552051901 51552051902 51927143300 54868345900 55390014701 55390014710 55390044701 55390044710 60505072703 62991203101 62991203102 62991203103 62991203104 63323047401 63323047410 63323047491 63370010215 63370010225 63370010235 00045025301 00045025303 00045025414 00703701103 00703701301 00703702103 00703702301 54868288900 54868288901 55390041201 55390041205 55390041301 55390041305 60505070201 60505070301 60505602002 60505602102 63323046901 63323046905 63323046951 63323047101 63323047105 63323047151 63323047155 67386070154 00074345425 00409115112 00409115170 00409115178 00409115212 00409115270 00409115278 00409128031 00409128032 00409128033 00409128035 00409128131 00409128132 12/19/2013 Earliest Start Date HCPCS Description INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL INJ 5MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HEMIN, 1 MG INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER PER PER PER PER PER PER PER PER PER PER PER PER 10 10 10 10 10 10 10 10 10 10 10 10 10 UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/10/2010 01/01/2002 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/24/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/30/2008 12/14/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2006 02/20/2002 07/14/2005 07/20/2005 09/19/2005 03/15/2005 09/07/2005 02/25/2005 03/28/2005 04/08/2005 04/05/2005 04/01/2005 07/22/2005 04/25/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2011 04/30/2011 05/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/30/2004 12/31/2078 12/31/2078 01/30/2004 11/30/2003 12/31/2078 11/01/2006 12/31/2078 12/31/2078 12/31/2078 07/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 00409128133 00409128135 00641027221 00641027225 00641027321 00641027325 00641038721 00641038725 00641038921 00641038925 00641039221 00641039225 00641039321 00641039325 00641041121 00641041125 00641041421 00641041425 00641243641 00641243645 00641243841 00641243845 00641244241 00641244245 00641244341 00641244345 08166110003 08166110005 08166111003 08166111005 08290034002 08290034003 08290035005 08290036003 08290036005 08290036006 08290036105 08290037002 08290037003 08290038003 08290038005 08290039003 08290039005 08290039105 08450602603 08450603005 08450603403 08450603705 08450604603 08450604903 08450605005 08450605503 08450605805 08881012502 08881580121 08881580123 08881580125 08881590121 08881590123 08881590125 17474012302 54868252600 54868361500 63323001710 63323054401 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN HEPARIN SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, SODIUM, (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN (HEPARIN LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK LOCK FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), FLUSH), PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT Earliest Start Date 07/15/2005 04/25/2005 05/05/2007 10/17/2005 05/05/2007 10/17/2005 12/08/2004 01/01/2002 12/08/2004 01/01/2002 12/08/2004 01/01/2002 12/08/2004 01/01/2002 12/08/2004 01/01/2002 12/08/2004 01/01/2002 05/05/2007 01/01/2002 05/05/2007 01/01/2002 05/05/2007 01/01/2002 05/05/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/01/2003 11/01/2003 11/01/2003 11/01/2003 11/01/2003 11/01/2003 11/01/2003 11/01/2003 11/01/2003 08/23/2006 03/14/2002 03/14/2002 08/23/2006 03/14/2002 03/14/2002 08/23/2006 03/14/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 11/28/2009 11/28/2009 12/31/2078 12/31/2078 07/28/2009 07/28/2009 12/28/2009 12/28/2009 09/28/2008 09/28/2008 07/28/2009 07/28/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2010 02/28/2010 06/28/2009 06/28/2009 07/28/2009 07/28/2009 12/28/2009 12/28/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1642 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 63323054411 63323054501 63323054505 63807030031 63807030035 63807040031 63807040035 63807050031 63807050051 63807060031 63807060051 63807060055 64054100301 64054100302 64054300302 64054300502 64253022221 64253022222 64253022223 64253022225 64253022230 64253022233 64253022235 64253033321 64253033322 64253033323 64253033325 64253033330 64253033333 64253033335 64253044421 64253044422 64253044423 64253044425 64253044430 64253044433 64253044435 68883001003 68883001005 68883001006 68883010003 68883010004 68883010005 68883010006 00264956710 00264957710 00264958720 00264987210 00338043103 00338043304 00338054903 00338055002 00338055003 00409131625 00409131632 00409131666 00409140231 00409258102 00409258402 00409272002 00409272101 00409272301 00409762003 00409762059 00409765062 12/19/2013 HCPCS Description INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS HEPARIN PER 1000 UNITS HEPARIN SODIUM PER 1,000 UNITS HEPARIN PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2007 04/12/2007 01/01/2007 04/12/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 05/10/2005 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/10/2003 10/10/2003 10/10/2003 10/10/2003 10/10/2003 10/10/2003 10/10/2003 01/05/2006 01/05/2006 01/05/2006 01/05/2006 01/05/2006 01/05/2006 01/05/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/08/2004 01/01/2002 10/29/2007 03/23/2005 02/11/2005 03/21/2005 03/24/2006 07/01/2005 08/31/2009 08/13/2009 08/31/2009 04/05/2005 04/13/2005 07/06/2005 Latest End Date 12/31/2078 12/31/2078 01/14/1999 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/01/2012 12/31/2078 12/31/2078 07/01/2012 07/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1644 J1645 J1645 J1645 J1645 J1645 J1645 J1645 J1645 J1645 J1645 J1645 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 00409765103 00409765162 00409776003 00409776103 00409779323 00409779362 00409779462 00641039102 00641039121 00641039125 00641039164 00641040002 00641040021 00641040025 00641040064 00641041002 00641041021 00641041025 00641041064 00641244041 00641244045 00641245041 00641245045 00641246041 00641246045 00641247041 00641247045 11743021002 25021040010 25021040030 25021040201 25021040301 49452345001 49452345002 49452345003 51927328600 63323004710 63323026201 63323027602 63323054001 63323054011 63323054031 63323054201 63323054207 63323091501 00013240691 00013242601 62856010110 62856010201 62856012510 62856015010 62856018010 62856025010 62856025101 62856050010 62856075010 00075062040 00075062041 00075062160 00075062161 00075062280 00075062281 00075062300 00075062301 00075062430 12/19/2013 HCPCS Description INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS HEPARIN SODIUM PER 1,000 UNITS HEPARIN SODIUM PER 1,000 UNITS HEPARIN SODIUM PER 1,000 UNITS HEPARIN NA 10000U/ML INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG Earliest Start Date 06/28/2005 07/28/2005 08/30/2005 07/22/2005 01/25/2006 10/14/2005 06/12/2006 10/01/2007 12/08/2004 01/01/2002 10/01/2007 10/01/2007 12/08/2004 01/01/2002 10/01/2007 10/01/2007 12/08/2004 01/01/2002 10/01/2007 12/08/2004 01/01/2002 12/08/2004 01/01/2002 12/08/2004 01/01/2002 12/08/2004 01/01/2002 01/01/2002 07/01/2010 07/16/2010 07/06/2010 07/06/2010 01/01/2002 01/01/2002 01/01/2002 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/14/2002 11/20/2006 07/10/2006 08/25/2007 08/25/2007 08/25/2007 06/26/2007 11/20/2006 10/10/2006 02/06/2007 01/01/2002 03/17/2008 01/01/2002 03/11/2008 01/01/2002 03/11/2008 01/01/2002 03/11/2008 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/28/2009 08/28/2009 08/28/2009 12/31/2078 02/28/2010 09/28/2009 09/28/2009 12/31/2078 01/28/2010 08/29/2008 08/29/2008 12/31/2078 12/28/2009 12/28/2009 12/28/2009 12/28/2009 02/28/2010 02/28/2010 01/28/2010 01/28/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2010 10/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1650 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1652 J1655 J1655 J1670 J1675 J1675 J1680 J1700 J1700 J1700 J1700 J1700 J1700 00075062431 00075062603 00075062604 00075291201 00075291501 00781311902 00781311963 00781311964 00781311966 00781311968 00781311969 00781312168 00781313363 00781322464 00781342868 00781350069 35356001810 35356001910 35356002010 54569574200 54569574201 54868511200 54868511201 54868544000 54868544001 54868558700 54868558701 54868583500 54868583700 58016487201 68115074910 68115077410 00007323002 00007323011 00007323202 00007323211 00007323402 00007323411 00007323602 00007323611 35356007802 35356007810 35356007902 35356007910 35356008002 35356008010 35356008102 35356008110 54868550100 54868550101 54868550102 54868565200 66203230001 67211034208 67211034253 13533063402 67979000201 67979050001 63833089151 00463103610 00574042101 00574042125 17317019901 17317019902 17317019903 12/19/2013 HCPCS Description INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG ENOXAPARIN 10MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG ENOXAPARIN 10MG ENOXAPARIN 10MG ENOXAPARIN 10MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, TINZAPARIN SODIUM, 1000 IU INJECTION, TINZAPARIN SODIUM, 1000 IU INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 100 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG Earliest Start Date 03/17/2008 03/07/2003 03/11/2008 01/01/2002 01/01/2002 07/01/2010 07/23/2010 07/23/2010 07/23/2010 07/23/2010 07/23/2010 07/23/2010 09/30/2011 09/30/2011 09/30/2011 09/30/2011 09/14/2007 09/14/2007 09/14/2007 10/24/2005 12/08/2005 07/28/2004 09/08/2004 09/29/2005 11/01/2005 05/17/2006 09/25/2007 11/29/2007 12/04/2007 04/01/2006 03/17/2004 02/06/2004 02/06/2006 06/03/2005 02/06/2006 11/16/2004 02/06/2006 11/16/2004 02/06/2006 11/16/2004 01/25/2008 01/25/2008 01/25/2008 01/25/2008 01/25/2008 01/25/2008 01/25/2008 01/25/2008 01/11/2006 01/11/2006 11/13/2006 08/04/2006 01/01/2003 01/01/2002 01/01/2002 10/14/2006 01/01/2012 01/01/2012 01/01/2012 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2013 06/30/2013 07/31/2013 07/31/2013 06/30/2013 07/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2013 12/31/2078 03/31/2014 12/31/2078 04/30/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2007 07/31/2011 09/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1700 J1720 J1720 J1720 J1720 J1720 J1720 J1720 J1720 J1720 J1720 J1720 J1720 J1730 J1730 J1730 J1730 J1730 J1730 J1740 J1740 J1742 J1743 J1744 J1744 J1745 J1750 J1750 J1750 J1750 J1751 J1751 J1752 J1752 J1752 J1752 17317019908 38779000801 38779000804 38779000805 38779000808 38779000809 39822509001 39822509003 39822509005 49452359001 49452359002 49452359003 49452359004 49452359006 51552002101 51552002102 51552002103 51552002104 51552002105 51927111000 62991107801 62991107802 62991107803 62991107804 62991107805 63370010815 63370010825 63370010835 63370010845 63370010850 00009001104 00009001306 00009082501 00009090013 00009090020 00009090908 00009090916 00009091205 00009092003 00409485605 54868060500 54868450800 38779032403 38779032404 38779032406 49452254102 49452254103 51927274200 00004018809 54868582300 00009379401 54092070001 54092070202 54092070203 57894003001 00517023410 52544093102 54868431900 54868471500 00517023410 52544093102 00517013410 00517023410 52544093102 54868431900 12/19/2013 Earliest Start Date HCPCS Description INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG HYDROCORTISONE NA SUCCINATE, UP TO 100MG HYDROCORTISONE NA SUCCINATE, UP TO 100MG INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP INJECTION, DIAZOXIDE, UP TO 300 MG INJECTION, DIAZOXIDE, UP TO 300 MG INJECTION, DIAZOXIDE, UP TO 300 MG INJECTION, DIAZOXIDE, UP TO 300 MG INJECTION, DIAZOXIDE, UP TO 300 MG INJECTION, DIAZOXIDE, UP TO 300 MG INJECTION, IBANDRONATE SODIUM, 1 MG INJECTION, IBANDRONATE SODIUM, 1 MG INJECTION, IBUTILIDE FUMARATE, 1 MG INJECTION, IDURSULFASE, 1 MG ICATIBANT, 1 MG INJ ICATIBANT, 1 MG INJ INJECTION INFLIXIMAB, 10 MG INJECTION, IRON DEXTRAN, 50MG INJECTION IRON DEXTRAN, 50MG INJECTION, IRON DEXTRAN, 50 MG INJECTION, IRON DEXTRAN, 50 MG INJECTION, IRON DEXTRAN 165, 50 MG INJECTION, IRON DEXTRAN 165, 50 MG INJECTION, IRON DEXTRAN 267, 50 MG INJECTION, IRON DEXTRAN 267, 50 MG INJECTION, IRON DEXTRAN 165, 50 MG INJECTION, IRON DEXTRAN 267, 50 MG TO TO TO TO TO TO TO TO TO TO 100 100 100 100 100 100 100 100 100 100 MG MG MG MG MG MG MG MG MG MG 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/12/2004 07/12/2004 07/12/2004 07/12/2004 07/12/2004 08/11/2010 09/30/1990 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/27/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/08/2003 01/01/2007 10/16/2007 01/01/2002 01/01/2008 01/01/2013 01/01/2013 01/01/2002 01/01/2010 01/01/2009 01/01/2009 01/01/2009 01/01/2008 01/01/2006 01/01/2006 01/01/2006 01/01/2007 03/20/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2012 05/31/2012 05/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/01/2014 02/01/2015 07/01/2014 12/31/2078 07/01/2014 05/01/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1752 J1756 J1756 J1756 J1756 J1756 J1756 J1785 J1785 J1790 J1790 J1790 J1790 J1790 J1790 J1790 J1790 J1790 J1790 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1800 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 54868471500 00517231005 00517234010 00517234025 49230053010 49230053410 49230053425 58468198301 58468466301 00409118701 00517970225 11098001001 11098001002 38779050100 38779050106 49452269601 49452269602 51927218200 54868389000 00781377795 10019014501 10019014543 38779018303 38779018304 38779018305 38779018308 49452608902 49452608903 49452608904 51552091004 51552091005 51927160600 54868387300 55390000310 63323060401 63370020525 63370020535 63370020545 66860009002 00002751001 00002751101 00002751201 00002751659 00002821501 00002821517 00002831501 00002861501 00002871501 00002872559 00002873059 00002877059 00002879359 00002879459 00002879759 00002879859 00002879959 00002951501 00088222033 00088222052 00088222060 00088250033 00088250052 00169183311 00169183411 00169183711 12/19/2013 HCPCS Description INJECTION, IRON DEXTRAN 267, 50 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, IMIGLUCERASE, PER UNIT INJECTION, IMIGLUCERASE, PER UNIT INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INJECTION, PROPRANOLOL HCL, UP TO 1 INSULIN 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INSULIN 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 01/01/2006 05/01/2007 01/01/2003 10/01/2006 12/23/2010 10/01/2008 10/01/2008 01/01/2002 01/01/2002 08/23/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/08/2003 01/01/2002 02/15/2007 01/15/2004 05/05/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/15/2004 11/15/2004 11/15/2004 09/01/2003 09/01/2003 09/08/2003 12/11/2006 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2003 01/01/2006 01/01/2003 11/01/2006 01/01/2003 01/01/2003 01/01/2010 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/20/2006 01/01/2003 12/10/2007 12/10/2007 12/10/2007 01/01/2003 01/01/2003 01/10/2005 07/09/2007 01/01/2006 01/24/2006 01/01/2003 01/01/2003 01/01/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2007 12/31/2078 08/01/2013 12/31/2078 12/31/2078 11/01/2011 07/01/2012 12/31/2078 12/31/2078 12/31/2078 05/31/2010 12/31/2078 06/30/2013 12/31/2078 12/31/2078 09/30/2011 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1815 J1817 J1817 J1817 J1817 J1817 J1817 J1817 J1817 J1817 J1817 J1830 J1835 J1835 J1835 J1835 J1835 J1835 J1835 00169231321 00169231421 00169231721 00169330312 00169347318 00169347418 00169347718 00169368213 00169368512 00169369619 00169633910 00169643910 00169750111 23490668700 49999099310 49999099410 54569231800 54569231900 54569291800 54569291802 54569346700 54569383300 54569383302 54569383500 54569383502 54569560500 54868142901 54868238001 54868274600 54868347400 54868359800 54868361900 54868438100 54868462600 54868520100 54868532700 54868576500 54868582400 54868589900 55045350601 55045350801 55045368501 58016478801 68115070905 68115072810 68115072905 68115083910 00002751001 00002850101 00088250033 00088250205 00169750111 35356010200 54868277700 54868510800 54868583600 68115074610 50419052325 38779193101 49452384501 49452384502 49452384503 49452384504 50458029801 51552092002 12/19/2013 HCPCS Description INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INSULIN 5 UNITS INSULIN 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INJECTION, INSULIN, PER 5 UNITS INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR INJECTION, ITRACONAZOLE, 50 MG INJECTION, ITRACONAZOLE, 50 MG INJECTION, ITRACONAZOLE, 50 MG INJECTION, ITRACONAZOLE, 50 MG INJECTION, ITRACONAZOLE, 50 MG INJECTION, ITRACONAZOLE, 50 MG INJECTION, ITRACONAZOLE, 50 MG Earliest Start Date 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 02/10/2003 01/01/2003 02/10/2003 03/27/2006 07/01/2003 04/30/2007 06/14/2007 06/14/2007 01/01/2003 01/01/2003 01/01/2003 09/22/2003 01/01/2003 01/01/2003 09/22/2003 01/01/2003 09/22/2003 02/16/2006 01/01/2003 07/16/2007 01/01/2003 01/01/2003 06/30/2005 01/01/2003 01/01/2003 01/01/2003 12/28/2004 06/09/2005 04/04/2007 10/16/2007 05/12/2008 06/28/2006 06/30/2006 11/15/2006 02/01/2006 03/17/2004 03/17/2004 03/17/2004 01/20/2004 01/01/2003 01/01/2003 01/24/2006 03/04/2009 01/01/2003 03/07/2008 05/07/2007 07/15/2004 12/03/2007 02/12/2004 01/02/2004 04/25/2002 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2002 09/01/2003 Latest End Date 07/31/2011 11/30/2011 01/31/2012 12/31/2078 07/31/2011 10/31/2011 07/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/29/2008 12/31/2078 Page 1 of 1 HCPCS NDC J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1835 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1840 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 51552092004 51552092005 51552092006 51927330600 62991256201 62991256202 62991256203 63275996302 63275996304 63275996305 63275996309 63370012215 63370012225 63370012235 38779198101 38779198104 38779198105 38779198108 49452388501 49452388502 49452388503 51552091301 51552091302 51927315800 63323035903 63370012420 63370012425 63370012435 00074228754 00074379601 00409228721 00409228722 00409228731 00409228761 00409228821 00409228831 00409379301 00409379349 00409379501 00409379549 00409379561 00409379601 00409379649 00409379661 00517060125 00517080125 00517090225 10019002109 10019002209 10019002232 10019002902 10019002912 10019003003 10019003004 10019003012 10019003017 12280045610 21695058825 23490579204 49452391901 49452391902 49452391903 49452391905 49999041602 54868384300 12/19/2013 Earliest Start Date HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG ITRACONAZOLE, 50 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KANAMYCIN SULFATE, UP TO 500 MG KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 KETOROLAC TROMETHAMINE, PER 15 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG 09/01/2003 09/01/2003 09/01/2003 09/08/2003 11/01/2005 11/01/2005 11/01/2005 06/04/2004 06/04/2004 06/04/2004 06/04/2004 07/08/2003 07/08/2003 07/08/2003 04/25/2002 04/25/2002 04/25/2002 04/25/2002 01/29/2002 01/29/2002 01/29/2002 09/01/2003 09/01/2003 09/08/2003 01/03/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 06/22/2007 06/22/2007 04/25/2005 06/20/2005 06/22/2007 08/29/2005 05/31/2005 04/19/2005 01/06/2006 09/21/2005 10/31/2005 12/21/2005 11/07/2005 08/05/2005 04/01/2008 04/01/2008 04/01/2008 01/01/2002 01/01/2002 01/01/2002 07/21/2004 05/05/2007 07/21/2004 07/21/2004 05/05/2007 05/05/2007 10/04/2005 08/09/2007 04/09/2007 01/01/2003 01/01/2003 01/01/2003 01/01/2003 07/06/2004 06/21/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/01/2007 04/01/2012 10/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2013 12/31/2078 05/31/2013 08/31/2013 05/31/2013 08/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1885 J1930 J1930 J1930 J1930 J1931 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 J1940 54868441900 54868441901 55390048001 55390048101 55390048102 55390048110 58016941301 60505070500 60505070600 60505070601 60505072501 60505072601 60505072602 63323016101 63323016201 63323016202 64679075701 64679075702 64679075801 64679075802 64679075804 64679075805 64679075806 66860008503 15054006001 15054009001 15054012001 15054012002 58468007001 00074963104 00409127532 00409163910 00409610202 00409610204 00409610210 00409963104 00517570225 00517570425 00517571025 00548143100 21695072125 23490562102 38779022604 38779022605 38779022608 49452322201 49452322202 49452322203 51552094002 51927178400 52637001010 54868229900 54868364500 54868499800 63323028002 63323028004 63323028010 64679075901 64679075902 64679075903 64679075904 64679075905 64679075906 64679075907 64679075908 12/19/2013 HCPCS Description INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC, 15MG INJ INJECTION, LANREOTIDE, 1 MG INJECTION, LANREOTIDE, 1 MG INJECTION, LANREOTIDE, 1 MG INJECTION, LANREOTIDE, 1 MG INJECTION, LARONIDASE, 0.1 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, FUROSEMIDE, UP TO 20 MG PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 01/01/2002 10/17/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/28/2005 02/28/2005 02/28/2005 11/01/2004 11/01/2004 11/01/2004 01/01/2002 01/01/2002 01/01/2002 04/12/2007 04/12/2007 04/12/2007 04/12/2007 04/12/2007 04/12/2007 04/12/2007 09/01/2008 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2005 01/01/2002 08/31/2005 01/23/2006 02/18/2005 02/21/2005 03/24/2005 04/21/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/20/2008 04/30/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2004 09/01/2003 09/08/2003 01/01/2002 09/29/2005 01/01/2002 02/18/2004 01/01/2002 01/01/2002 01/01/2002 04/12/2007 04/12/2007 04/12/2007 04/12/2007 04/12/2007 04/12/2007 04/12/2007 04/12/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2010 11/30/2009 12/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J1940 J1945 J1950 J1950 J1950 J1950 J1950 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1955 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1956 J1960 J1960 J1960 J1960 J1960 J1960 J1960 J1960 J1960 J1960 J1960 J1980 J1980 J1980 J1980 J1980 J1980 J1980 J1990 J2001 J2001 J2001 J2001 J2001 64679075909 50419015057 00074364103 00300364101 00300366301 54868282500 54868327700 00517104525 00703040402 00703040502 49452177501 49452177502 49452177503 49452177601 49452177602 51927186500 54482014701 55390013605 55390043605 63370041435 63370041445 63370041450 63370041453 88395006764 00045006555 00045006601 00045006701 00045006801 00045006951 00045151501 00781334209 25021013282 25021082582 38779236305 50458016420 50458016601 50458016701 50458016801 55045353201 62991270702 62991270703 00406073552 38779088503 38779088506 49452920101 49452920105 49452920106 51927100700 63275120001 63275120002 63275120004 63275120007 00091153605 49452365601 49452365602 51552014102 51552014104 51927183100 68220011105 00187375574 00074132305 00074490334 00074621702 00186011001 00186011201 12/19/2013 HCPCS Description INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, LEPIRUDIN, 50 MG LEUPROLIDE ACETATE, 3.75MG INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3. LEUPROLIDE ACETATE, 3.75MG INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3. INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3. INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVOFLOXACIN, 250 MG INJ, LEVOFLOXACIN, PER 250MG LEVOFLOXACIN INJ, PER 250 MG LEVOFLOXACIN INJ, PER 250 MG INJECTION, LEVOFLOXACIN, 250 MG LEVOLFLOXACIN 250MG INJ LEVOFLOXACIN INJ, PER 250 MG LEVOFLOXACIN INJ, PER 250 MG INJ, LEVOFLOXACIN, PER 250MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJ, HYOSCAMINE SULFATE, 0.25MG INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG Earliest Start Date 04/12/2007 01/01/2006 09/09/2009 01/01/2002 01/01/2006 03/10/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2004 01/01/2002 01/01/2002 12/04/2003 01/01/2002 01/01/2002 01/01/2002 10/24/2006 10/24/2006 10/24/2006 10/24/2006 09/03/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/05/2004 07/08/2011 07/07/2011 12/28/2011 10/25/2007 11/01/2009 08/04/2010 08/04/2010 08/04/2010 01/02/2007 01/01/2008 01/01/2008 01/01/2002 11/22/2002 11/22/2002 11/14/2004 11/15/2004 11/15/2004 09/08/2003 12/03/2002 12/03/2002 12/03/2002 12/03/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/08/2003 09/01/2009 01/01/2002 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 Latest End Date 12/31/2078 06/20/2014 12/31/2078 08/01/2011 10/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2011 12/31/2011 12/31/2011 12/31/2011 09/30/2010 02/28/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/12/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/01/2007 08/01/2007 12/31/2078 05/31/2013 12/31/2012 Page 1 of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escription INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE LIDOCAINE HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL HCL FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INTRAVENOUS INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 12/08/2005 09/06/2005 10/31/2005 02/27/2006 12/30/2005 08/12/2005 07/07/2005 06/13/2005 08/12/2005 06/29/2005 08/31/2005 09/09/2005 02/08/2006 05/16/2005 11/21/2005 09/06/2005 02/06/2006 12/01/2005 08/23/2005 05/18/2005 09/16/2005 01/11/2006 06/30/2005 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 Latest End Date 01/31/2013 10/31/2012 12/31/2012 03/31/2013 05/31/2013 05/31/2013 02/28/2013 06/30/2012 03/31/2013 10/31/2012 03/31/2013 12/31/2078 06/30/2013 05/31/2013 10/31/2012 12/31/2078 12/31/2078 12/31/2078 09/30/2012 05/31/2013 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2012 07/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2011 11/30/2008 08/31/2011 09/30/2014 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2001 J2010 J2010 08888714113 12280023001 17317073501 17317073502 17317073503 17317073504 17317073506 35356018050 38779008204 38779008205 38779008208 38779008209 49452405001 49452405002 49452405003 49999067150 51552010604 51552010605 51552010606 51552010609 51927121300 54569531200 54569531201 54868179500 54868179801 54868206400 54868206401 54868233100 54868233101 54868339200 54868389400 54868429800 54868571900 55045323101 55045324905 55553005550 55553005650 58016484001 58016933101 62991109501 62991109502 62991109503 62991109504 62991109506 63275999104 63275999105 63275999108 63323020102 63323020110 63323020202 63323020805 63323048450 63323049205 63323049257 63323049505 63323049507 63323049527 63370014514 63370014525 63370014535 63370014550 63370014555 66312017014 00009055501 00009055502 12/19/2013 HCPCS Description INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS LIDOCAINE HCL FOR INFUSION, PER 10MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS LIDOCAINE HCL FOR INFUSION, PER 10MG LIDOCAINE HCL FOR INFUSION, PER 10MG LIDOCAINE HCL FOR INFUSION, PER 10MG LIDOCAINE HCL FOR INFUSION, PER 10MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INJECTION, LINCOMYCIN HCL, UP TO 300 MG INJECTION, LINCOMYCIN HCL, UP TO 300 MG INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG INFUSION, 10 MG INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, INFUSION, 10 10 10 10 10 10 MG MG MG MG MG MG Earliest Start Date 01/01/2004 08/16/2005 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 05/16/2008 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 05/16/2008 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 11/08/2007 11/08/2007 01/01/2004 01/01/2004 01/01/2004 06/23/2006 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 12/11/2006 07/01/2006 07/01/2006 01/01/2004 01/01/2004 02/01/2006 08/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 04/01/2008 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 07/02/2010 10/01/2004 01/20/2011 02/26/2010 08/05/2011 09/30/1990 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 08/15/2006 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/30/2014 03/30/2014 12/31/2078 01/30/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2010 J2010 J2010 J2010 J2010 J2010 J2010 J2020 J2020 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 38779003404 38779003405 38779003408 51552067405 51552067407 51927317700 54569138700 00009513701 00009514001 00409153931 00409198501 00409198505 00409198510 00409198530 00409677802 00409677862 00409677902 00409678002 00409678102 00591336545 00591336570 00641604425 10019010201 10019010210 10019010237 10019010239 10019010301 10019010310 10019010337 10019010339 10019010501 10019010502 10019010544 10019010571 10019010601 10019010602 10019010644 10019010671 17478004001 38779092701 38779092703 38779092704 38779092705 38779092706 38779092708 49452414001 49452414002 49452414003 49452414004 51552072901 51552072902 51552072904 51552072905 51552072909 51927100500 54868356600 54868356601 54868356602 55390016810 55390016910 55390017010 55390017110 60977011201 60977011202 60977011271 12/19/2013 HCPCS Description INJECTION, LINCOMYCIN HCL, UP INJECTION, LINCOMYCIN HCL, UP INJECTION, LINCOMYCIN HCL, UP INJECTION, LINCOMYCIN HCL, UP INJECTION, LINCOMYCIN HCL, UP INJECTION, LINCOMYCIN HCL, UP INJECTION, LINCOMYCIN HCL, UP INJECTION, LINEZOLID, 200MG INJECTION, LINEZOLID, 200MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG LORAZEPAM INJ PER 2MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG TO TO TO TO TO TO TO 300 300 300 300 300 300 300 MG MG MG MG MG MG MG Earliest Start Date 01/01/2002 01/01/2002 08/26/2002 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 12/23/2005 04/25/2005 02/08/2008 11/16/2005 06/01/2005 01/27/2006 06/28/2005 01/05/2006 12/29/2005 01/23/2006 02/22/2005 02/22/2005 04/01/2012 01/01/2002 01/01/2002 05/05/2007 05/05/2007 01/01/2002 01/01/2002 05/05/2007 05/05/2007 05/03/2006 05/03/2006 05/05/2007 05/05/2007 05/03/2006 05/03/2006 05/05/2007 05/05/2007 03/28/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/10/2007 09/13/2006 09/13/2006 09/13/2006 09/13/2006 02/13/2004 02/13/2004 05/05/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2008 08/30/2008 12/31/2078 02/28/2014 08/31/2013 08/31/2013 02/28/2014 01/31/2014 12/31/2013 12/31/2078 01/31/2014 11/30/2013 09/30/2013 11/30/2013 09/30/2013 01/31/2014 12/31/2013 01/31/2014 12/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2014 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2060 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2150 J2170 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 60977011281 60977011301 60977011302 60977011371 60977011381 62991168201 62991168202 63275997902 63275997904 63275997905 63370093510 63370093515 63370093525 63370093535 00409403101 00517405025 10106255505 17317101001 17317101003 17317101005 17317101008 17317101101 17317101105 17317101108 17317101109 17317101201 17317101203 17317101208 38779059901 38779059908 38779059909 49452438001 49452438002 49452438003 51552038001 51552038005 51552038006 51552038008 51552038009 51927178100 62991156801 63323002425 15054104005 00074117921 00074117930 00074118130 00074120301 00074125502 00074603004 00338269175 00406158555 00409117630 00409117830 00409117930 00409118069 00409118130 00409120120 00409120301 00409125301 00409125401 00409125502 00409125601 00409603004 00641605225 00641605425 12/19/2013 Earliest Start Date HCPCS Description INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, LORAZEPAM, 2 MG INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MECASERMIN, 1 MG INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, INJECTION, MEPERIDINE HYDROCHLORIDE, MEPERIDINE, 100MG INJ MEPERIDINE, 100MG INJ PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG 05/05/2007 02/13/2004 02/13/2004 05/05/2007 05/05/2007 10/01/2002 10/01/2002 12/04/2002 12/04/2002 12/04/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 10/19/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 12/04/2003 09/15/2003 01/01/2002 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/25/2005 09/14/2005 12/08/2005 09/14/2005 01/31/2006 03/09/2006 12/16/2005 01/04/2006 03/20/2006 11/23/2005 01/26/2006 01/02/2007 10/07/2011 12/01/2011 Latest End Date 02/28/2014 01/31/2014 12/31/2013 12/31/2013 01/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/01/2007 09/01/2009 11/01/2009 05/01/2009 09/01/2007 09/30/2010 01/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2175 J2185 J2185 J2185 J2185 J2185 J2210 J2210 J2212 J2212 J2212 J2212 J2248 J2248 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 10019015568 10019015768 10019015868 10019015901 10019015944 10019016001 10019016044 10019016101 10019016144 10019016201 10019016244 38779176603 38779176604 38779176605 49452003101 49452003102 49452003103 51552068601 51552068602 51552068604 51552068606 51927101800 54868061600 54868323001 54868361000 54868475100 54868475101 54868580800 58298054325 61553017041 61553017248 61553017348 63275710004 63275710005 63370093715 63370093725 63370093735 00310032130 00310032165 00310032520 00310032564 00409350601 00078005303 00517074020 65649055102 65649055103 65649055204 65649055305 00469321110 00469325010 00074259603 00409230502 00409230505 00409230517 00409230549 00409230550 00409230561 00409230562 00409230622 00409230662 00409230721 00409230760 00409230801 00409230802 00409230849 12/19/2013 HCPCS Description INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEROPENEM, 100 MG INJECTION, MEROPENEM, 100 MG INJECTION, MEROPENEM, 100 MG INJECTION, MEROPENEM, 100 MG MEROPENEM INJ, PER 100MG INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG METHYLERGONOVINE, INJ, PER 0.2MG INJ, METHYLNALTREXONE, 0.1MG INJ, METHYLNALTREXONE, 0.1MG INJ, METHYLNALTREXONE, 0.1MG INJ, METHYLNALTREXONE, 0.1MG INJECTION, MICAFUNGIN SODIUM, 1 MG INJECTION, MICAFUNGIN SODIUM, 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG MIDAZOLAM 1MG INJ INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG Earliest Start Date 03/27/2002 03/27/2002 03/27/2002 01/07/2004 05/05/2007 01/07/2004 05/05/2007 01/07/2004 05/05/2007 01/07/2004 05/05/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 03/11/2003 07/03/2003 08/21/2007 04/03/2006 02/02/2004 02/02/2004 02/02/2004 12/03/2002 12/03/2002 07/08/2003 07/08/2003 07/08/2003 01/01/2004 07/17/2006 01/01/2004 07/17/2006 06/24/2010 01/01/2002 06/21/2010 01/01/2013 01/01/2013 01/01/2013 01/01/2013 01/01/2007 01/01/2007 01/01/2002 08/15/2005 12/21/2005 10/01/2007 08/02/2005 09/13/2005 10/03/2005 10/03/2005 07/20/2007 03/10/2005 07/20/2007 04/25/2005 06/07/2005 10/10/2005 12/29/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 02/28/2013 02/28/2013 04/30/2013 04/30/2013 09/28/2009 09/28/2009 03/31/2013 03/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/18/2015 12/31/2078 01/31/2014 12/31/2078 03/31/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/01/2012 12/31/2078 12/31/2078 05/01/2012 12/31/2078 07/01/2011 08/01/2011 01/01/2012 12/31/2078 06/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2250 J2260 J2260 J2260 J2260 00409230850 00409258705 00409258753 00409259603 00409259605 00409259652 00409259653 00641605710 00641605910 10019002701 10019002702 10019002703 10019002704 10019002705 10019002709 10019002710 10019002729 10019002736 10019002737 10019002739 10019002764 10019002802 10019002803 10019002804 10019002805 10019002810 10019002836 10019002837 10019002839 23490593201 23490593301 23490593302 54868458000 54868571100 55045285701 55045288702 55390012510 55390012605 55390012610 55390013702 55390013705 55390013801 55390013802 59911591102 59911591402 59911591502 61703032107 61703032132 61703032142 61703032153 63323041110 63323041112 63323041125 63323041202 63323041205 63323041210 63323041225 66758001801 66758001802 66758001901 66758001902 00024120301 00024120302 00024120315 00074277501 12/19/2013 HCPCS Description INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, MIDAZOLAM 1MG INJ MIDAZOLAM 1MG INJ INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, MIDAZOLAM 1MG INJ INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, MIDAZOLAM 1MG INJ INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, MIDAZOLAM 1MG INJ INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MIDAZOLAM HYDROCHLORIDE, INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG PER PER PER PER PER PER PER 1 1 1 1 1 1 1 MG MG MG MG MG MG MG PER PER PER PER PER 1 1 1 1 1 MG MG MG MG MG PER PER PER PER PER 1 1 1 1 1 MG MG MG MG MG PER 1 MG PER 1 MG PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 11/18/2005 01/27/2006 03/07/2006 10/28/2005 01/11/2006 01/23/2006 09/27/2005 04/01/2012 01/01/2012 12/08/2005 01/01/2002 12/10/2003 12/10/2003 12/08/2005 06/21/2000 01/01/2002 05/05/2007 05/05/2007 05/05/2007 05/05/2007 04/01/2009 12/08/2005 12/10/2003 06/21/2000 01/01/2002 01/01/2002 05/05/2007 05/05/2007 05/05/2007 04/30/2007 04/30/2007 04/30/2007 01/01/2002 12/27/2006 12/01/2005 08/27/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/08/2003 01/01/2002 01/01/2002 01/01/2002 01/07/2004 10/02/2003 10/02/2003 10/02/2003 10/02/2003 01/01/2002 01/01/2002 01/01/2002 06/05/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/28/2011 12/31/2078 03/28/2011 12/31/2078 10/30/2008 06/30/2013 05/31/2013 12/31/2078 12/31/2078 12/31/2078 05/31/2013 06/30/2013 04/28/2011 04/28/2011 11/30/2013 10/31/2013 10/31/2013 12/31/2078 10/31/2013 10/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2008 03/31/2009 12/31/2078 01/01/2007 Page 1 of 1 HCPCS NDC J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2260 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 00143970801 00143970910 00143971810 00143971910 00338601048 00338601137 00409277502 00409277602 00409277623 00703800503 00703800603 00703800801 10019007001 10019007002 10019007010 10019007020 10139005710 10139005720 55390001910 55390002010 55390002101 55390007410 55390007510 55390007601 59911590502 59911590602 59911590702 60505071800 60505071801 61703024221 61703024232 61703024250 63323061710 63323061720 63323061750 67457016020 00074602804 00338268975 00338269075 00409125830 00409126069 00409126130 00409176230 00409189001 00409189101 00409381512 00409405812 00409606202 00409606211 00409617714 00409617914 00548191125 00548193110 00548193310 00548193700 00548290125 00548339110 00548604225 00548604325 00548604525 00641017021 00641017025 00641606801 00641607025 00641607325 12/19/2013 HCPCS Description INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO MS04 2MG/ML MS04 4MG/ML INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO INJECTION, MORPHINE SULFATE, UP TO 10 10 10 10 10 10 10 MG MG MG MG MG MG MG 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 03/29/2011 03/29/2011 02/23/2011 02/23/2011 06/05/2002 06/05/2002 12/31/2004 03/08/2006 06/15/2005 06/19/2003 06/19/2003 06/19/2003 05/22/2002 05/22/2002 05/05/2007 05/05/2007 04/15/2005 04/07/2005 05/31/2002 05/31/2002 05/31/2002 05/31/2002 05/31/2002 05/31/2002 05/31/2002 05/31/2002 05/31/2002 02/28/2005 02/28/2005 09/23/2002 09/23/2002 09/23/2002 05/14/2002 05/14/2002 05/14/2002 10/30/2003 01/01/2002 01/01/2002 01/01/2002 05/10/2005 03/22/2006 07/21/2005 05/27/2005 08/23/2012 09/23/2012 06/28/2005 10/07/2005 01/10/2006 07/22/2005 07/14/2005 09/01/2005 01/01/2002 01/01/2002 01/01/2002 01/23/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/08/2004 01/01/2002 02/08/2012 02/08/2012 02/08/2012 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2008 06/30/2008 12/31/2078 06/30/2013 06/30/2013 06/30/2013 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/29/2012 02/29/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/01/2008 09/30/2010 12/31/2078 09/01/2013 10/01/2013 03/01/2014 11/01/2013 12/31/2078 12/31/2078 12/31/2078 08/01/2011 07/01/2011 10/01/2011 12/31/2078 12/31/2078 12/31/2078 09/30/2011 02/28/2009 02/28/2009 10/31/2010 08/31/2012 02/28/2010 10/31/2008 03/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2270 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 J2271 00641607525 10019017639 10019017644 10019017737 10019017739 10019017744 10019017768 10019017836 10019017837 10019017839 10019017844 10019017862 10019017868 10019017939 54868418900 54868475200 54868475201 54868480400 54868574500 61553017741 61553017848 61553017948 61553018102 61553018348 61553018502 61553018667 61553018775 61703022321 00406152153 00406152155 00406152156 00406152157 00409113403 00409113405 00409126431 00409602804 00574200625 00641019021 00641019025 00641607125 00641607201 10019017936 10019017944 10019017963 10019017968 38779067303 38779067304 38779067305 38779067307 49452002801 49452002802 49452002803 49452002804 51552067802 51552067804 51552067806 51927100000 54868405000 58298054501 58298054502 61553064975 61553065176 61703022521 61703022543 63275102504 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, SULFATE, UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 UP TO 10 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100 MG 100 MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG 100MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 02/08/2012 08/21/1998 01/01/2002 05/05/2007 09/13/2001 01/01/2002 01/01/2002 05/05/2007 08/21/1998 05/05/2007 12/22/2005 01/01/2002 01/01/2002 05/05/1999 01/01/2002 03/11/2003 05/26/2004 05/30/2003 01/10/2007 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/14/2005 08/08/2005 12/16/2005 03/23/2007 01/01/2002 12/08/2004 01/01/2002 02/08/2012 02/08/2012 05/05/2007 01/01/2002 01/01/2002 09/06/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 04/03/2006 04/03/2006 03/03/2005 03/03/2005 01/01/2002 01/01/2002 12/03/2002 Latest End Date 12/31/2078 10/31/2013 10/31/2013 01/13/2012 01/31/2013 01/31/2013 01/13/2012 07/31/2013 01/13/2012 11/30/2013 11/30/2013 07/31/2013 01/13/2012 01/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/01/2013 12/31/2078 01/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2013 01/31/2013 10/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2271 J2271 J2271 J2271 J2271 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2275 J2278 J2278 J2278 J2278 J2278 J2278 J2280 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 J2300 63275110005 63370095025 63370095035 63370095045 63370095050 00186115002 00186115102 00186115212 00186115312 00186115903 00186116003 00409113502 00409189001 00409189101 00409189301 00409189401 00409381412 00409381512 00409405712 00555112710 00555112810 00555112910 00555113010 00641601910 00641602010 00641603901 00641604001 60977001602 60977001673 60977001701 60977001773 60977011401 60977011474 60977011501 60977011574 63323029180 63323029280 18860072010 18860072210 18860072310 59075072010 59075072210 59075072310 00085173701 00409146301 00409146401 00409146501 00409146701 00555111909 00555112009 00555112105 00555112205 23490595501 49452480001 49452480002 49452480003 51927214000 54569411200 54569579500 54868347100 54868360800 54868360801 54868360900 54868368600 54868368601 12/19/2013 Earliest Start Date HCPCS Description INJECTION, MORPHINE SULFATE, 100MG INJECTION, MORPHINE SULFATE, 100MG INJECTION, MORPHINE SULFATE, 100MG INJECTION, MORPHINE SULFATE, 100MG INJECTION, MORPHINE SULFATE, 100MG INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE MSO4 PF PER 10MG INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE INJ, MSO4, PF, PER 10MG MSO4, PF, PER 10MG INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, ZICONOTIDE, 1 MICROGRAM INJECTION, MOXIFLOXACIN, 100 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT SOLUT 12/03/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/21/2005 08/23/2012 08/06/2012 08/15/2012 08/10/2012 07/19/2005 09/30/1990 12/13/2005 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/03/2012 07/03/2012 07/25/2012 07/25/2012 01/15/2004 05/05/2007 01/15/2004 05/05/2007 01/01/2004 05/05/2007 01/01/2004 05/05/2007 10/01/2009 02/26/2010 01/31/2011 01/31/2011 01/31/2011 01/01/2006 01/01/2006 01/01/2006 08/17/2005 03/09/2005 07/13/2005 11/18/2004 05/12/2005 05/25/2007 05/25/2007 05/25/2007 05/25/2007 04/09/2007 01/29/2002 01/29/2002 01/29/2002 09/08/2003 01/01/2002 05/12/2006 01/01/2002 01/01/2002 05/24/2007 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2012 03/31/2012 08/31/2011 12/31/2078 11/30/2011 04/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/01/2012 06/30/2011 03/31/2011 10/31/2010 10/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2015 02/28/2015 02/28/2015 02/28/2015 10/31/2014 10/31/2014 09/30/2014 09/30/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/01/2013 04/01/2013 01/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2011 11/30/2010 03/31/2011 02/28/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 00078018101 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 01/01/2004 12/31/2078 J2354 00078018201 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 01/01/2004 12/31/2078 J2354 00078018325 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 01/01/2004 12/31/2078 J2354 00078018425 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 01/01/2004 12/31/2078 HCPCS NDC J2300 J2300 J2300 J2300 J2300 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2310 J2315 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2321 J2322 J2322 J2322 J2322 J2323 J2323 J2325 J2353 J2353 J2353 J2354 58016477001 58016938401 63481043210 63481043310 63481050905 00074121901 00074178221 00406149252 00409121201 00409121501 00409121901 00409178269 00548146600 00548146900 00548336600 00548336900 38779076703 38779076706 49452483602 49452483603 49452483604 51927333500 54569524700 54868074800 54868206200 55045351501 63481035810 76329336901 63459030042 00591671702 00591671747 49452483803 49452483804 49452483805 51552104302 51927351400 54868555500 62991218602 62991218603 62991218604 62991218605 63370095510 63370095515 63370095525 63370095535 63370095545 00591218653 00591218654 54868489300 54868489301 59075073015 64406000801 65847020525 00078034061 00078034161 00078034261 00078018001 J2354 12/19/2013 HCPCS Description INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG NALOXONE HCL, 1MG/ML INJECTION, NALTREXONE, DEPOT FORM, 1 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 200 MG INJECTION, NANDROLONE DECANOATE, UP TO 200 MG INJECTION, NANDROLONE DECANOATE, UP TO 200 MG INJECTION, NANDROLONE DECANOATE, UP TO 200 MG INJECTION, NATALIZUMAB, 1 MG INJECTION, NATALIZUMAB, 1 MG INJECTION, NESIRITIDE, 0.1 MG INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTIO INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTIO INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTIO INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 02/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/07/2005 01/01/2002 01/01/2002 06/16/2005 07/08/2005 04/03/2006 09/29/2005 01/01/2002 01/01/2002 01/15/2002 01/15/2002 01/01/2002 01/01/2002 04/15/2002 04/16/2002 04/16/2002 09/08/2003 01/01/2002 01/01/2002 01/01/2002 07/12/2006 01/01/2002 04/19/2012 01/01/2007 04/29/2003 04/29/2003 01/01/2003 01/01/2003 01/01/2003 09/01/2003 09/08/2003 04/11/2006 01/01/2008 01/01/2008 01/01/2008 01/01/2008 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/09/2003 07/09/2003 08/13/2003 08/14/2003 01/01/2008 04/02/2013 01/01/2006 07/26/2004 08/18/2004 07/14/2004 01/01/2004 12/31/2078 12/31/2078 01/31/2007 11/30/2006 10/31/2006 11/01/2006 12/31/2078 12/31/2078 01/01/2012 12/31/2078 12/31/2078 12/31/2078 05/31/2008 01/31/2014 05/31/2008 02/28/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2006 12/31/2078 05/31/2010 12/31/2078 06/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2009 12/31/2078 12/31/2078 12/31/2078 10/31/2016 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J2354 J2354 00703330101 OCTREOTIDE 25MCG, SC OR IV 00703330104 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN J2354 J2354 00703331101 OCTREOTIDE 25MCG, SC OR IV 00703331104 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 01/01/2007 11/14/2005 12/31/2078 12/31/2078 J2354 J2354 00703332101 OCTREOTIDE 25MCG, SC OR IV 00703332104 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 01/01/2007 11/14/2005 12/31/2078 12/31/2078 J2354 00703333301 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 11/23/2005 12/31/2078 J2354 00703334301 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 11/23/2005 12/31/2078 J2354 00781916475 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/07/2005 06/29/2014 J2354 00781916575 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/07/2005 11/17/2014 J2354 00781916695 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/07/2005 12/31/2078 J2354 00781916795 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/07/2005 12/31/2078 J2354 00781916895 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/07/2005 12/31/2078 J2354 55390016010 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 05/04/2005 12/31/2078 J2354 55390016110 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/04/2005 12/31/2078 J2354 55390016210 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/04/2005 12/31/2078 J2354 55390016301 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 05/25/2005 12/31/2078 J2354 55390016401 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 05/25/2005 12/31/2078 J2354 J2354 62756034844 OCTREOTIDE 25MCG, SC OR IV 63323036501 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 10/19/2007 04/13/2006 12/31/2078 12/31/2078 J2354 63323037601 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/13/2006 12/31/2078 J2354 63323037701 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 04/13/2006 12/31/2078 J2354 63323037805 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 05/12/2006 12/31/2078 J2354 63323037905 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR IN 05/12/2006 12/31/2078 J2355 J2355 J2355 J2355 J2357 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2360 J2370 J2370 J2370 54868556900 58394000401 58394000402 58394000408 50242004062 00089054006 00463109210 00591322247 10139023010 11584101602 11584101605 17478053802 49452493601 49452493602 51552083905 51927211800 52959017906 55390005910 55553012910 00074180001 00409180001 00517029925 04/13/2006 01/01/2002 01/01/2002 09/01/2008 01/01/2005 01/01/2002 01/01/2002 09/07/2004 01/05/2007 01/01/2002 01/01/2002 10/01/2006 05/15/2002 05/15/2002 09/01/2003 09/08/2003 01/01/2002 04/28/2003 01/01/2002 01/01/2002 04/14/2005 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/01/2010 08/01/2014 12/31/2078 12/19/2013 INJECTION, OPRELVEKIN, 5 MG INJECTION, OPRELVEKIN, 5 MG INJECTION, OPRELVEKIN, 5 MG OPRELEVKIN, 5MG INJECTION, OMALIZUMAB, 5 MG INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, ORPHENADRINE CITRATE, UP TO 60 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML MG MG MG MG MG MG MG MG MG MG MG MG MG MG 01/01/2007 11/14/2005 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2370 J2370 J2370 J2370 J2370 J2370 J2370 J2370 J2370 J2370 J2400 J2400 J2400 J2400 J2400 J2400 J2400 J2400 J2400 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 00517040525 00703163104 10019016301 10019016312 54868571600 66758001601 66758001602 66758001603 66758001604 66758001701 00186097166 00186097266 00186099166 00186099266 00409416901 00409417001 54868492500 55390040320 55390040420 00143977106 00143989105 00173044200 00173044202 00173046100 00338176241 00409112062 00409475501 00409475502 00409475503 00409475561 00409475562 00409475901 00409476013 00641607825 00641608001 00641608025 00703722102 00703722103 00703722104 00703722601 00703722603 00703723939 00781301072 00781301095 00781305714 00781305780 10019090501 10019090502 10019090503 10019090517 10019090603 10019090663 23360001602 23360001620 25021077702 54569587400 54868450900 54868588800 55390012101 55390012110 55390030701 55390030710 60505074401 60505074406 61703024407 12/19/2013 Earliest Start Date HCPCS Description INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL INJ, PER 1MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL INJ, PER 1MG ONDANSETRON HCL INJ, PER 1MG ONDANSETRON HCL INJ, PER 1MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL INJ, PER 1MG ONDANSETRON HCL INJ, PER 1MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL INJ, PER 1MG ONDANSETRON HCL INJ, PER 1MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL INJ, PER 1MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ML ML ML ML ML ML ML ML ML 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/11/2006 01/08/2004 01/08/2004 06/08/2005 06/08/2005 01/08/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/20/2005 04/20/2005 09/25/2003 01/01/2002 01/01/2002 02/05/2009 04/03/2007 01/01/2002 01/01/2002 01/01/2002 12/27/2006 01/22/2007 12/26/2006 08/24/2007 01/01/2009 12/26/2006 10/01/2007 12/26/2006 02/01/2007 11/09/2011 11/09/2011 11/09/2011 11/22/2006 11/22/2006 11/22/2006 11/22/2006 11/22/2006 11/22/2006 01/01/2009 01/01/2009 11/22/2006 11/22/2006 12/26/2006 06/04/2009 06/24/2009 05/05/2007 12/26/2006 05/05/2007 10/15/2008 10/15/2008 09/17/2012 01/12/2007 01/01/2002 05/09/2008 12/26/2006 12/26/2006 12/26/2006 12/26/2006 12/26/2006 12/26/2006 12/26/2006 Latest End Date 12/31/2078 10/31/2012 08/30/2011 07/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2010 12/31/2078 01/01/2013 07/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2012 04/01/2009 07/25/2012 03/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/01/2011 12/31/2078 12/31/2078 12/31/2078 06/30/2011 12/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2011 01/31/2010 09/30/2013 09/30/2013 09/30/2013 09/30/2013 07/31/2013 07/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2405 J2410 J2410 J2425 J2425 J2426 J2426 J2426 J2426 J2426 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2430 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 61703024522 61703041549 62756018101 62756018201 62991259901 62991259902 63275995501 63275995506 63275995507 63323037302 63323037420 64679072601 64679072701 66860008706 63481044410 63481062410 55513052001 55513052006 50458056001 50458056101 50458056201 50458056301 50458056401 00078046391 00078046461 00703407559 00703408551 00703408591 00781314784 00781314870 15210040111 15210040211 55390012701 55390012901 55390015701 55390015901 55390020401 55390060401 61703032418 61703032439 61703032518 61703032618 61703035618 63323073410 63323073435 63323073510 63323073535 00517400225 00517401001 17317039801 17317039804 38779045403 38779045404 38779045405 49452500001 49452500002 49452500003 51552041602 51552041604 51552041605 51552041607 51927177500 55390010710 62991120302 62991120304 12/19/2013 Earliest Start Date HCPCS Description INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ONDANSETRON HCL INJ, PER 1MG INJECTION, OXYMORPHONE HCL, UP TO 1 MG INJECTION, OXYMORPHONE HCL, UP TO 1 MG INJECTION, PALIFERMIN, 50 MICROGRAMS INJECTION, PALIFERMIN, 50 MICROGRAMS INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG 1 1 1 1 1 MG MG MG MG MG 12/26/2006 12/26/2006 12/27/2006 12/27/2006 01/01/2006 01/01/2006 01/27/2005 01/27/2005 01/27/2005 12/27/2006 12/27/2006 12/26/2006 12/26/2006 09/01/2008 01/01/2002 05/07/2007 01/01/2006 01/01/2006 09/01/2009 09/01/2009 09/01/2009 09/01/2009 09/01/2009 07/13/2006 07/13/2006 11/08/2005 11/08/2005 07/01/2003 10/03/2005 10/03/2005 07/12/2006 07/12/2006 01/01/2002 01/01/2002 01/01/2003 01/01/2003 04/02/2002 04/02/2002 12/15/2006 09/15/2005 01/27/2003 09/15/2005 12/15/2006 04/25/2002 07/20/2004 04/25/2002 09/11/2003 09/15/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 09/15/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/29/2012 09/30/2011 12/31/2078 12/31/2078 12/31/2078 02/28/2010 05/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2012 08/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2440 J2460 J2460 J2460 J2469 J2469 J2469 J2469 J2501 J2501 J2501 J2501 J2503 J2504 J2505 J2505 J2507 J2510 J2510 J2510 J2510 J2515 J2515 J2515 J2540 J2540 J2540 J2540 J2540 J2540 J2540 J2540 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 J2543 63275999002 63275999004 63275999005 63370016515 63370016525 63370016535 66758001401 66758001402 66758001501 38779004205 51552106902 51927325800 58063079725 58063079737 62856079701 62856079801 00074165801 00074165802 00074165805 00074463701 68782000101 57665000101 54868522900 55513019001 54396080101 60793013010 60793013110 61570008510 61570008610 51927361300 67386050152 67386050155 00049052083 00049053028 00338102141 00338102341 00338102541 00781613595 00781613694 54868448800 00206845216 00206845217 00206845417 00206845455 00206845517 00206845525 00206862011 00206882002 00206882102 00206882202 00206885216 00206885218 00206885408 00206885416 00206885418 00206885516 00206885518 00206885910 00206886002 00206886102 00206886202 00409338513 00409339004 60505068704 12/19/2013 HCPCS Description INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG INJECTION, PALONOSETRON HCL, 25 MCG INJECTION, PALONOSETRON HCL, 25 MCG INJECTION, PALONOSETRON HCL, 25 MCG INJECTION, PALONOSETRON HCL, 25 MCG INJECTION, PARICALCITOL, 1 MCG INJECTION, PARICALCITOL, 1 MCG PARACALCITOL, 1MCG INJECTION, PARICALCITOL, 1 MCG INJECTION, PEGAPTANIB SODIUM, 0.3 MG INJECTION, PEGADEMASE BOVINE, 25 IU INJECTION, PEGFILGRASTIM, 6 MG INJECTION, PEGFILGRASTIM, 6 MG INJECTION, PEGLOTICASE, 1 MG INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNI INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNI INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNI INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNI INJECTION, PENTOBARBITAL SODIUM, PER 50 MG INJECTION, PENTOBARBITAL SODIUM, PER 50 MG INJECTION, PENTOBARBITAL SODIUM, PER 50 MG INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 PIPERCILLIN/TAZOBACTAM PER 1.125GM TOTAL INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 PIPERCILLIN/TAZOBACTAM PER 1.125GM TOTAL INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/ 0. PIPERACILLIN/TAZOBACTAM PER 1GM Earliest Start Date 12/04/2002 12/04/2002 12/04/2002 07/08/2003 07/08/2003 07/08/2003 02/20/2004 02/20/2004 02/20/2004 04/25/2002 09/01/2003 09/08/2003 01/01/2005 07/02/2008 04/01/2009 07/10/2008 01/01/2003 01/01/2003 05/25/2011 01/01/2003 01/01/2006 01/01/2006 02/23/2006 01/01/2004 01/01/2012 09/14/2007 09/14/2007 12/04/2002 12/06/2002 03/26/2004 06/11/2003 06/11/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/25/2002 11/25/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/05/2006 04/28/2006 10/01/2009 03/06/2006 04/05/2006 03/13/2006 04/05/2006 04/28/2006 01/09/2006 01/09/2006 01/09/2006 10/22/2010 10/22/2010 10/01/2009 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2011 05/31/2011 09/30/2011 12/31/2078 12/31/2078 12/31/2078 08/31/2011 02/28/2011 12/31/2078 12/31/2078 12/31/2078 07/01/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2014 08/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2007 08/31/2007 02/28/2008 06/30/2007 07/31/2007 11/30/2007 12/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2008 12/31/2078 06/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J2545 54868252800 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRO J2545 J2545 63323011310 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED F 63323087715 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRO 07/05/1991 01/01/2007 12/31/2078 12/31/2078 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2550 J2560 00143986822 00143986922 00409231202 00409231231 00591315754 00591315783 00591315883 00641092821 00641092921 00641092925 00641094831 00641094931 00641095521 00641095621 00641149531 00641149631 00641608225 00703219104 00703220104 10019009701 10019009744 38779025304 38779025305 38779025308 38779025309 39822550003 49452608701 49452608702 49452608704 51552014701 51552014702 51552014704 51552014705 51927901800 54868026200 54868026201 54868059700 54868208800 54868269500 54868402100 55045351401 60977000101 60977000103 60977000143 60977000144 60977000202 60977000204 60977000243 60977000244 62991112501 62991112502 62991112504 63370020325 63370020335 63370020345 63370020350 66860009803 66860009903 67457015210 00409234331 08/04/2008 08/04/2008 08/29/2008 04/05/2005 01/20/2003 01/23/2003 01/23/2003 12/08/2004 12/08/2004 12/27/2002 12/08/2004 05/05/2007 05/05/2007 05/05/2007 05/05/2007 05/05/2007 01/01/2012 09/30/2002 09/30/2002 01/17/2005 05/05/2007 01/01/2002 01/01/2002 01/01/2002 09/03/2002 08/12/2011 02/28/2002 02/28/2002 02/28/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 09/29/2005 01/01/2002 09/29/2005 01/01/2002 01/01/2002 07/12/2006 01/01/2004 10/21/2004 05/05/2007 05/05/2007 01/01/2004 10/21/2004 05/05/2007 05/05/2007 01/01/2002 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 03/26/2009 03/26/2009 07/01/2005 09/19/2005 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2009 03/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2013 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2014 04/30/2013 01/31/2014 04/30/2013 04/30/2014 12/31/2078 04/30/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE INJ UP TO 50MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG 01/01/2007 12/31/2078 Page 1 of 1 HCPCS NDC J2560 J2560 J2560 J2560 J2560 J2560 J2560 J2560 J2562 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2590 J2597 J2597 J2597 J2597 J2597 J2597 J2597 J2597 J2597 J2650 J2650 J2650 J2650 J2650 J2650 J2650 J2650 J2650 J2650 J2650 J2650 J2670 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 00409234931 00641047621 00641047721 17317041301 38779085304 38779085305 49452520003 54868385901 58468014001 00591355369 00703627104 00703627503 10019029102 10019029104 10019029112 10019029171 42023011601 42023011625 61553073203 61570041605 63323001201 63323001210 63323001212 63323001230 00075245101 00075245153 00406806103 00409226501 00703505103 00703505401 54868388900 55566503001 55566504001 00463101930 00463102010 51927132500 52637032510 62991169201 62991169202 62991169203 63370019515 63370019525 63370019535 63370019550 63370019555 51927259300 00517075001 00574043000 00574043001 00574043025 00574043100 00574043101 00574043125 00574043200 00591312879 17317062601 17317062602 17317062603 17317062608 17317093401 17317093402 17317093403 17317093408 38779004301 38779004304 12/19/2013 HCPCS Description INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG PLERIXAFOR, 1MG INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, TOLAZOLINE HCL, UP TO 25 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROGESTERONE, PER 50 MG Earliest Start Date 09/07/2005 12/08/2004 12/08/2004 01/01/2002 05/23/2002 05/23/2002 01/01/2002 01/01/2002 12/30/2008 12/06/2006 01/24/2008 01/24/2008 05/07/2007 05/07/2007 05/29/2007 05/29/2007 02/29/2008 02/01/2008 02/06/2004 01/01/2002 01/01/2002 01/01/2002 01/28/2008 09/24/2007 01/01/2002 01/01/2002 01/01/2002 02/04/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/08/2003 01/01/2002 09/01/2002 09/01/2002 09/01/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 09/08/2003 09/29/2010 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/17/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2009 04/30/2011 01/28/2011 02/28/2013 01/31/2013 02/28/2013 01/31/2013 12/31/2078 12/31/2078 12/31/2078 05/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2011 07/31/2010 12/31/2078 07/31/2010 07/31/2013 07/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 38779004305 38779004308 38779004309 38779005701 38779005704 38779005705 38779005709 38779031009 39822600001 39822600003 39822600007 39822610001 39822610003 39822610007 49452606002 49452606003 49452606004 49452606006 49452606102 49452606103 49452606104 49452606105 49452607001 49452607002 49452607003 49452607004 49452607006 49452608002 49452608003 49452608004 49452608006 51552000501 51552000503 51552000504 51552000505 51552000507 51552000601 51552000603 51552000604 51552000605 51552000607 51552064307 51552073804 51552073805 51552073806 51552073807 51552082901 51552082903 51552082904 51552082905 51552082906 51552082907 51552082908 51927104600 51927353000 51927901700 62991112203 62991112205 62991112402 62991112403 62991112405 62991218401 62991218402 62991218403 62991218404 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PROGESTERONE, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 01/01/2002 04/25/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 09/08/2003 09/08/2003 09/15/2003 09/15/2003 01/01/2002 10/01/2007 10/01/2007 09/01/2002 09/01/2002 09/01/2002 09/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2013 02/28/2013 02/28/2013 06/30/2013 06/30/2013 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2675 J2680 J2680 J2680 J2680 J2680 J2690 J2690 J2690 J2690 J2690 J2690 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2700 J2710 J2710 J2710 J2710 J2710 J2710 62991250402 62991250403 62991250404 63275998105 63275998108 63275998109 63323026110 63370019935 63370019945 63370019950 63370019955 63370019962 63370020035 63370020045 63370020050 63370020055 63370020235 63370020245 63370020250 63370020435 63370020445 63370020450 63370020455 63370020462 00703500301 51927223400 55390046505 60505066402 63323027205 00409190201 00409190301 51552039704 51552039705 51927311500 54868313600 00015797018 00015797089 00015798118 00015798189 00338101341 00338101541 00781309415 00781309492 00781309580 00781309592 00781309995 00781310180 00781310195 00781310395 00781910985 00781910995 00781911015 00781911092 00781911180 00781911195 00781911220 00781911292 00781911346 00781911395 00517003325 00517003425 00703270403 00703271103 00703271403 10019027010 12/19/2013 Earliest Start Date HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG PROGESTERONE, PER 50 MG FLUPHENAZINE DECANOATE, UP TO 25 MG FLUPHENAZINE DECANOATE, UP TO 25 MG FLUPHENAZINE DECANOATE, UP TO 25 MG FLUPHENAZINE DECANOATE, UP TO 25 MG FLUPHENAZINE DECANOATE, UP TO 25 MG PROCAINAMIDE HCL, UP TO 1 GM PROCAINAMIDE HCL, UP TO 1 GM PROCAINAMIDE HCL, UP TO 1 GM PROCAINAMIDE HCL, UP TO 1 GM PROCAINAMIDE HCL, UP TO 1 GM PROCAINAMIDE HCL, UP TO 1 GM OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG OXACILLIN SODIUM, UP TO 250 MG NEOSTIGMINE METHYLSULFATE, UP TO 0.5 NEOSTIGMINE METHYLSULFATE, UP TO 0.5 NEOSTIGMINE METHYLSULFATE, UP TO 0.5 NEOSTIGMINE METHYLSULFATE, UP TO 0.5 NEOSTIGMINE METHYLSULFATE, UP TO 0.5 NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG MG MG MG MG MG 09/15/2003 09/15/2003 09/15/2003 12/04/2002 12/04/2002 12/04/2002 01/01/2002 02/25/2004 02/25/2004 02/25/2004 02/25/2004 02/25/2004 12/19/2003 12/19/2003 07/08/2003 12/19/2003 07/12/2004 07/12/2004 07/12/2004 02/25/2004 02/25/2004 02/25/2004 02/25/2004 02/25/2004 01/01/2002 09/08/2003 01/01/2002 01/01/2002 01/01/2002 03/10/2006 08/24/2005 09/01/2003 09/01/2003 09/08/2003 02/18/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/19/2008 03/19/2008 03/19/2008 03/19/2008 02/08/2005 02/01/2007 07/02/2004 08/31/2004 02/01/2007 03/01/2006 03/19/2008 03/19/2008 02/01/2007 05/04/2006 03/19/2008 03/19/2008 02/01/2007 05/03/2006 01/15/2003 01/15/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2009 02/28/2009 07/31/2013 Page 1 of 1 HCPCS NDC J2710 J2710 J2710 J2710 J2710 J2710 J2715 J2720 J2720 J2720 J2720 J2720 J2720 J2720 J2724 J2724 J2725 J2730 J2730 J2730 J2730 J2730 J2730 J2730 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2760 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 10019027039 10019027102 10019027110 51552070102 63323038210 63323038310 00641605225 49452610901 49452610902 49452610903 63323022905 63323022915 63323022930 63323022935 00944417505 00944417510 51927348400 00641037401 49452597101 49452597102 49452597103 51927230000 60977014101 60977014127 38779150200 38779150203 38779150206 38779150209 49452521701 49452521702 49452521704 49452521705 51552049601 51552049602 51552049604 51552049605 51552049609 51927266900 55390011301 62991110801 62991110802 62991110803 62991110804 63275998901 63275998906 63275998907 63370017006 63370017009 63370017010 63370017015 00409217332 00409341301 00409341401 00703450204 10019045002 10019045039 23490591401 38779040301 38779040304 38779040305 49452471501 49452471502 49452471503 51552018003 51552018004 12/19/2013 HCPCS Description NEOSTIGMINE, 0.5MG, INJ INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU INJECTION, PROTIRELIN, PER 250 MCG INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG METOCLOPRAMIDE, 10MG, INJ INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG Earliest Start Date 10/01/2009 01/01/2002 01/01/2002 09/01/2003 01/01/2002 01/01/2002 10/07/2011 01/01/2003 01/01/2003 01/01/2003 01/01/2002 01/07/2008 01/01/2002 01/07/2008 01/01/2008 01/01/2008 09/08/2003 12/08/2004 01/01/2003 01/01/2003 01/01/2003 12/04/2003 12/20/2004 05/05/2007 01/01/2002 05/22/2002 01/01/2002 05/22/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 09/15/2003 09/15/2003 12/04/2002 12/04/2002 12/04/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 11/28/2005 04/21/2005 01/01/2007 01/01/2002 01/01/2002 05/05/2007 04/09/2007 04/25/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 Latest End Date 07/31/2013 06/30/2007 07/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2013 01/13/2012 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2765 J2770 J2778 J2778 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2780 J2783 J2783 J2785 J2788 J2788 J2788 J2788 J2788 J2788 J2790 J2790 J2790 J2790 51552018005 51927108200 54868416700 58016481101 60977045101 60977045102 60977045103 60977045117 60977045171 60977045182 61703021007 61703021011 61703021021 61703021031 61703021035 62991204201 62991204202 62991204203 63370014115 63370014125 63370014135 61570026010 50242008001 50242008201 00173036238 00173036300 00173036301 00173044100 38779053604 38779053605 38779053608 38779053609 49452621201 49452621204 49452621205 49452621206 51552062002 51552062004 51552062005 51927302300 54868577500 55390061601 55390061610 55390061801 62991113201 62991113202 62991113203 62991113204 63370021825 63370021835 63370021845 63370021850 00024515010 00024515175 00469650189 00562780601 00562780605 00562780625 00562780801 00562780806 00562780826 00562780501 00562780505 00562780525 13533063102 12/19/2013 HCPCS Description INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350) INJECTION, RANIBIZUMAB, 0.1 MG INJECTION, RANIBIZUMAB, 0. 1 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RASBURICASE, 0.5 MG INJECTION, RASBURICASE, 0.5 MG 0.1MG REGADENOSON INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICR INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICR INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICR INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICR Earliest Start Date 09/01/2003 09/08/2003 01/01/2002 02/01/2006 01/01/2004 01/01/2004 01/01/2004 05/05/2007 05/05/2007 05/05/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/01/2003 01/01/2002 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 06/27/2003 01/01/2008 11/05/2012 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/20/2002 05/20/2002 05/20/2002 05/20/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 06/06/2007 11/22/2004 11/22/2004 03/29/2006 09/15/2003 09/15/2003 09/15/2003 09/15/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2004 06/27/2006 01/01/2010 09/01/2007 09/01/2007 09/01/2007 08/08/2006 01/01/2003 01/01/2003 09/01/2007 09/01/2007 09/01/2007 10/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/13/2012 01/13/2012 01/13/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2790 J2790 J2791 J2791 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2792 J2793 J2794 J2794 J2794 J2794 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2795 J2796 J2796 J2800 J2800 J2800 J2800 J2800 J2800 J2800 J2800 J2800 J2800 J2800 J2805 J2810 J2810 J2810 J2810 J2810 44206030001 44206030010 44206030001 44206030010 00944295002 00944295004 00944295006 00944296701 00944296703 00944296705 00944296707 00944296709 13533063102 13533063106 53270300001 53270310001 53270330001 53270350001 54569576400 61755000101 50458030611 50458030711 50458030811 50458030911 00186085944 00186085954 00186085977 00186085981 00186085991 00186086354 00186086361 00186086369 00186086377 00186086754 00186086844 00186086854 00186086877 63323028520 63323028564 63323028567 63323028620 63323028630 63323028631 63323028637 63323028810 63323028820 55513022101 55513022201 12280022901 38779194305 38779194308 38779194309 51552101805 51927251900 60977015001 60977015071 63370014335 63370014345 63370014350 00270055615 00074766823 00264955400 00264955410 00264955810 00264955820 12/19/2013 HCPCS Description INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTR INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTR INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN INJECTION, RILONACEPT, 1 MG INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG ROPIVICAINE HCL, 1MG ROPIVICAINE HCL, 1MG ROPIVICAINE HCL, 1MG INJ, ROPIVICAINE HCL, PER 1 MG INJ, ROPIVICAINE HCL, PER 1 MG ROPIVICAINE HCL, 1MG ROPIVICAINE HCL, 1MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG ROMIPLOSTIN, PER 10MCG ROMIPLOSTIN, PER 10MCG INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, SINCALIDE, 5 MICROGRAMS INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG Earliest Start Date 01/01/2006 01/01/2002 01/01/2008 01/01/2008 03/25/2005 03/25/2005 03/25/2005 03/01/2006 03/01/2006 03/01/2006 03/01/2006 03/01/2006 12/21/2005 12/21/2005 06/01/2010 06/01/2010 06/01/2010 06/01/2010 01/12/2006 01/01/2012 01/01/2005 01/01/2005 01/01/2005 04/23/2007 01/01/2002 01/01/2002 01/19/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/19/2007 01/01/2002 01/01/2002 01/01/2002 08/21/2006 10/01/2009 10/01/2009 11/01/1996 07/20/2009 07/20/2009 02/26/2010 07/01/2009 11/01/1996 11/01/1996 01/01/2010 01/01/2010 08/16/2005 04/25/2002 04/25/2002 04/25/2002 09/01/2003 09/08/2003 01/01/2004 05/05/2007 07/08/2003 07/08/2003 07/08/2003 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2012 09/30/2012 10/31/2012 10/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2013 04/30/2013 06/30/2013 12/31/2078 04/30/2013 03/31/2012 03/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2014 04/30/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/01/2007 12/31/2078 12/31/2078 09/30/2013 12/31/2078 Page 1 of 1 HCPCS NDC J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2810 J2820 J2820 J2820 J2820 J2820 J2820 J2820 J2850 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 00338043903 00338044103 00409766503 00409766509 00409766603 00409766662 00409766823 00409767713 00409770562 17317057101 17317057104 17317057105 17317057108 38779181605 38779181608 49452772001 49452772002 49452772003 51552048705 51927151000 50419000233 50419005030 50419059501 50419059505 54868318800 58468018002 58468018101 67066000601 00074181222 00074210205 00074536505 00223849602 00223849605 00409191832 00409191833 00409191835 00409210202 00409210205 00517280225 00641049517 08166110903 08166110905 08290031002 08290031003 08290032003 08290032005 08290033003 08290033005 08290033006 08290033010 08290091002 08290091003 08290092005 08290093010 08290094010 08290095010 08450090102 08450090303 08450090505 08450090610 55045371001 58016499501 63323018602 63807010011 63807010030 12/19/2013 HCPCS Description INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG SARGRAMOSTIM, 50MCG SARGRAMOSTIM, 50MCG INJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAM INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML Earliest Start Date 01/01/2002 01/01/2002 12/29/2005 04/25/2005 05/27/2006 01/27/2006 02/06/2007 08/10/2006 05/27/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/01/2002 05/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/08/2003 10/23/2003 10/23/2003 06/29/2007 01/30/2006 05/23/2006 01/01/2010 01/01/2010 01/01/2006 01/01/2002 09/13/2005 01/01/2002 01/01/2002 01/01/2002 11/23/2005 02/17/2005 04/08/2005 08/16/2005 04/03/2006 01/01/2002 12/08/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/01/2005 11/01/2003 11/01/2003 11/01/2003 11/01/2003 07/24/2006 07/01/2006 01/01/2002 01/01/2002 01/01/2002 Latest End Date 09/30/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2912 J2916 J2916 J2916 J2920 J2920 J2920 J2920 J2920 J2920 J2920 J2920 J2920 J2920 J2920 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 J2930 63807010033 63807010035 63807010050 63807010051 63807010056 63807010075 63807010092 63807010211 64253011121 64253011122 64253011123 64253011125 64253011130 64253011133 64253011135 68883090001 68883090003 68883090004 68883090005 68883090010 68883090016 00024279150 00024279210 52544092226 00009003928 00009011312 00009011319 00009019016 00409321705 00409568401 00409568423 54868076800 55390020910 58016489701 63323025503 00009004722 00009004725 00009011319 00009019009 00009019016 00009069801 00009075801 00009076502 00009079601 00009338901 00409321805 00409568502 00409568523 12280023201 21695058710 51927355200 54569155500 54569155501 54868362300 54868363700 54868363701 55045350901 55390021010 55390021801 55390021901 55390025801 55390025901 58016945201 63323025803 63323026530 12/19/2013 HCPCS Description INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML SODIUM FERRIC GLUCONATE COMPLEX PER 12.5MG SODIUM FERRIC GLUCONATE COMPLEX PER 12.5MG INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECT METHYLPREDNISOLONE, 40MG METHYLPREDNISOLONE NA SUCC, UP TO 40MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG METHYLPREDNISOLONE SOD SUCC, 40MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG METHYLPREDNISOLONE INJ, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG METHYLPREDNISOLONE NA SUCC, UP TO 125MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG Earliest Start Date 01/01/2002 05/25/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/05/2006 01/05/2006 01/05/2006 01/05/2006 01/05/2006 01/05/2006 05/07/2010 04/14/2011 01/02/2003 01/01/2010 01/01/2007 01/01/2002 01/01/2006 10/02/2006 11/01/2005 09/30/1990 01/01/2002 02/22/2007 07/01/2006 09/22/2004 09/30/1990 08/04/2010 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/02/2006 11/01/2005 08/12/2009 08/18/2005 08/09/2007 09/08/2003 01/01/2002 06/05/2002 01/01/2002 01/01/2002 01/01/2002 07/10/2006 02/22/2007 02/22/2007 02/22/2007 02/01/2008 02/01/2008 01/01/2002 08/23/2004 10/27/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2014 12/31/2078 10/31/2011 12/31/2078 08/31/2009 01/01/2012 12/01/2012 12/31/2078 12/31/2078 05/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/01/2012 12/01/2012 12/01/2012 12/31/2078 12/31/2078 09/01/2011 12/31/2078 11/01/2012 12/31/2078 12/31/2078 05/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2941 J2993 J2993 J2993 J2993 J2995 J2997 J2997 J2997 J2997 J3000 J3000 J3000 J3000 00002733511 00002733516 00002814701 00002814801 00002814901 00013262681 00013262694 00013264681 00013264694 00013264902 00013265002 00013265102 00013265202 00013265302 00013265402 00013265502 00013265602 00013265702 00013265802 00169770411 00169770511 00169770811 00169776811 00169777011 00781300107 00781300126 00781300144 00781400436 12280007215 12280009215 44087000407 44087000507 44087000607 44087008804 44087100502 44087108001 44087108801 44087338807 50242001821 50242001902 50242002020 50242002220 50242004314 50242007203 50242007301 54569493000 54868560100 54868563400 54868576000 57844071319 57844071341 58016477101 67286004001 67286004002 67286040001 67286040002 00053177001 50242004163 50242004164 50242004413 50242008527 38779081304 38779081305 38779081308 38779081309 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG SOMATROPIN, 1 MG RETEPLASE, 18.1 MG RETEPLASE, 18.1 MG RETEPLASE, 18.1 MG RETEPLASE, 18.1 MG STREPTOKINASE, PER 250,000 IU ALTEPLASE RECOMBINANT, 1 MG ALTEPLASE RECOMBINANT, 1 MG ALTEPLASE RECOMBINANT, 1 MG ALTEPLASE RECOMBINANT, 1 MG STREPTOMYCIN, UP TO 1 GM STREPTOMYCIN, UP TO 1 GM STREPTOMYCIN, UP TO 1 GM STREPTOMYCIN, UP TO 1 GM Earliest Start Date 03/01/2006 01/01/2002 08/30/2005 08/30/2005 08/30/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/24/2005 01/02/2006 01/24/2005 01/01/2002 01/01/2002 03/12/2008 03/12/2008 03/12/2008 01/15/2007 03/21/2005 03/23/2005 01/01/2002 01/01/2002 01/01/2002 10/15/2007 01/01/2002 10/22/2004 01/01/2002 04/07/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/10/2002 01/01/2002 01/28/2008 01/01/2002 05/22/2006 06/30/2006 08/17/2007 01/18/2005 01/18/2005 02/01/2006 11/30/2005 11/30/2005 03/10/2008 03/10/2008 09/17/2002 01/18/2007 01/01/2002 01/01/2002 01/01/2002 05/15/2002 05/15/2002 05/15/2002 05/15/2002 Latest End Date 12/31/2078 03/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2009 12/31/2078 09/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2012 09/30/2012 09/30/2012 03/31/2012 11/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2013 05/31/2012 11/30/2013 03/31/2013 12/31/2078 05/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2008 12/31/2078 12/31/2078 12/31/2078 04/30/2011 04/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3000 J3000 J3000 J3000 J3000 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 39822070602 51552097805 51927178800 63370023335 63370023350 00074909332 00074909335 00074909336 00074909338 00074909428 00074909431 00406113052 00409127632 00409909332 00409909335 00409909336 00409909338 00409909422 00409909425 00409909428 00409909431 00409909461 00641602410 00641602510 00641602605 00641602725 00641602825 00641602925 00641603001 10019003372 10019003473 10019003574 10019003639 10019003682 10019003727 10019003730 10019003783 10019003867 11098003002 11098003005 11098003010 11098003020 38779175600 38779175603 38779175606 38779175609 49452003201 49452003202 51552068701 51552068709 51927101900 54868373800 54868373801 58298052502 58298052505 61553010702 61553010972 61553011148 61553011248 61553011302 61553011402 61553011648 61553011841 61553060248 61553073068 12/19/2013 HCPCS Description INJECTION, STREPTOMYCIN, UP TO 1 GM INJECTION, STREPTOMYCIN, UP TO 1 GM INJECTION, STREPTOMYCIN, UP TO 1 GM INJECTION, STREPTOMYCIN, UP TO 1 GM INJECTION, STREPTOMYCIN, UP TO 1 GM INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG FENTANYL CITRATE, 0.1MG INJ FENTANYL CITRATE, 0.1MG INJ INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG Earliest Start Date 01/01/2002 09/01/2003 09/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/27/2005 11/14/2005 12/13/2005 07/12/2006 03/03/2006 10/12/2005 11/07/2005 02/14/2006 09/23/2005 12/30/2005 10/10/2012 11/13/2012 10/10/2012 07/25/2012 07/25/2012 10/10/2012 07/25/2012 01/01/2002 01/01/2002 01/01/2002 08/21/1998 01/01/2002 08/04/2010 08/04/2010 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/23/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 04/03/2006 04/03/2006 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 11/21/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/01/2007 09/01/2007 09/01/2007 09/01/2007 09/01/2007 04/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2015 06/28/2010 12/31/2078 01/28/2009 01/28/2009 05/31/2014 04/30/2014 05/31/2014 04/30/2015 12/31/2011 07/31/2011 12/31/2078 09/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3010 J3030 J3030 J3030 J3030 J3030 J3030 J3030 J3030 J3030 J3030 J3030 J3030 J3030 J3070 J3070 J3070 J3070 J3100 J3101 J3105 J3105 J3105 J3105 J3105 J3105 J3105 J3110 J3110 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3130 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 61553079168 61553079268 61553079368 61553079468 61553079568 63275510001 63275510002 63275510006 63370092006 63370092009 63370092010 63370092015 00173044902 00173073900 00173073902 00703735102 00781317414 54569370400 54868265200 54868265201 54868318100 55045351201 55390031510 63323027301 68115077002 00409192010 00409194101 21695024101 54868253000 50242003861 50242003861 00143974610 00703127104 55390010110 55390019310 63323066501 66591043411 66591043511 00002897101 54868540600 00574082105 00591322126 38779085503 38779085504 49452764901 49452764902 49452764903 54396032816 54396032840 54868501600 62991270001 63370098315 63370098325 63370098335 63370098350 00463106910 00574046005 00574046025 17317056702 17317056703 17317056708 38779016303 38779016304 38779016305 38779016308 12/19/2013 Earliest Start Date HCPCS Description INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY SUMATRIPTIN INJ, PER 6 MG SUMATRIPTIN INJ, PER 6 MG INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY INJECTION, PENTAZOCINE, 30 MG INJECTION, PENTAZOCINE, 30 MG INJECTION, PENTAZOCINE, 30 MG INJECTION, PENTAZOCINE, 30 MG INJECTION, TENECTEPLASE, 50MG INJECTION, TENECTEPLASE, 1 MG TERBUTALINE 1MG INJ INJECTION, TERBUTALINE SULFATE, UP TO 1 MG INJECTION, TERBUTALINE SULFATE, UP TO 1 MG INJECTION, TERBUTALINE SULFATE, UP TO 1 MG INJECTION, TERBUTALINE SULFATE, UP TO 1 MG INJECTION, TERBUTALINE SULFATE, UP TO 1 MG INJECTION, TERBUTALINE SULFATE, UP TO 1 MG INJECTION, TERIPARATIDE, 10 MCG INJECTION, TERIPARATIDE, 10 MCG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG BE BE BE BE BE BE BE BE BE BE USED USED USED USED USED USED USED USED USED USED FOR FOR FOR FOR FOR FOR FOR FOR FOR FOR BE USED FOR 12/01/2006 12/01/2006 12/01/2006 12/01/2006 12/01/2006 12/03/2002 09/01/2002 12/03/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2002 03/17/2006 03/17/2006 02/06/2009 01/01/2009 01/01/2002 01/01/2002 08/28/2006 01/01/2002 07/11/2006 01/01/2010 03/04/2009 01/20/2004 09/29/2005 11/18/2005 01/01/2007 01/01/2002 01/01/2002 01/01/2009 10/01/2010 07/22/2004 04/28/2004 11/19/2004 06/21/2004 05/23/2003 09/21/2004 01/01/2005 09/06/2005 08/01/2007 03/09/2004 04/25/2002 04/25/2002 01/01/2003 01/01/2003 01/01/2003 01/01/2002 01/01/2002 03/09/2004 01/01/2008 01/19/2004 01/19/2004 01/19/2004 01/19/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/30/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2012 12/31/2078 12/31/2078 03/01/2012 12/31/2078 12/31/2078 12/31/2078 06/30/2012 06/30/2012 12/31/2078 12/31/2011 12/31/2078 06/30/2012 12/31/2078 12/31/2078 12/31/2078 12/01/2009 12/31/2078 09/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3140 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3150 J3230 J3230 J3230 J3230 J3230 J3230 38779016309 49452765001 49452765002 49452765003 49452765201 49452765202 49452765203 51552002901 51552002902 51552002904 51552002907 51552056404 51552056405 51552056407 51927102600 51927102700 62991215001 62991215002 62991215003 62991215004 63275998304 63275998305 63275998308 63275998309 63370097025 63370097035 63370097045 63370097050 63370097125 63370097135 63370097145 63370097150 00463107310 00574046105 00574046125 17317056802 17317056803 17317056808 38779016503 38779016504 38779016505 38779016508 49452001101 49452001102 49452001103 51552003001 51552003002 51552003004 51552003005 51552003008 51552003009 51927102900 62991141201 62991141202 62991141203 63370098525 63370098535 63370098545 63370098550 00641139731 00641139835 38779042304 38779042305 49452199001 49452199002 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE SUSPENSION, UP TO 50 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG TESTOSTERONE PROPIONATE, UP TO 100 MG CHLORPROMAZINE HCL, UP TO 50 MG CHLORPROMAZINE HCL, UP TO 50 MG CHLORPROMAZINE HCL, UP TO 50 MG CHLORPROMAZINE HCL, UP TO 50 MG CHLORPROMAZINE HCL, UP TO 50 MG CHLORPROMAZINE HCL, UP TO 50 MG Earliest Start Date 04/30/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 09/08/2003 09/01/2002 09/01/2002 09/01/2002 09/01/2002 12/04/2002 12/04/2002 12/04/2002 12/04/2002 01/31/2002 01/31/2002 01/31/2002 01/31/2002 12/19/2003 12/19/2003 12/19/2003 12/19/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/30/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 09/01/2002 09/01/2002 09/01/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 05/05/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3230 J3230 J3230 J3230 J3230 J3240 J3243 J3243 J3246 J3246 J3246 J3246 J3246 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3250 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3260 J3262 J3262 J3262 J3265 J3265 J3285 J3285 J3285 J3285 J3301 J3301 J3301 J3301 J3301 J3301 J3301 J3301 J3301 J3301 J3301 49452199003 51552013904 51552013905 51552013907 51927309800 58468184904 00008499002 00008536002 25208000201 25208000202 61379012001 61379012002 61379012005 00409195232 00463110820 38779219603 38779219604 38779219605 42023011801 42023011925 49452792401 49452792402 49452792403 51927198100 51927357200 54868060800 54868075600 55045356501 61570054120 61570054325 00074357801 00409325503 00409346913 00409347023 00409357701 00409357801 00409359002 00703940204 00703941601 54868410600 63323030502 63323030602 63323030630 63323030655 63323030751 50242013501 50242013601 50242013701 00004026706 00004026806 66302010101 66302010201 66302010501 66302011001 00003029305 00003029320 00003029328 00003049420 00065054301 00781324375 00781324572 35356008201 51552003301 54569182701 54868023400 12/19/2013 HCPCS Description INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIA INJECTION, TIGECYCLINE, 1 MG INJECTION, TIGECYCLINE, 1 MG INJECTION, TIROFIBAN HCL, 0.25MG INJECTION, TIROFIBAN HCL, 0.25MG INJECTION, TIROFIBAN HCL, 0.25MG INJECTION, TIROFIBAN HCL, 0.25MG INJECTION, TIROFIBAN HCL, 0.25MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG TOCLIZUMAB, PER 1MG INJECTION, TOCILIZUMAB, 1 MG TOCLIZUMAB, PER 1MG INJECTION, TORSEMIDE, 10 MG/ML INJECTION, TORSEMIDE, 10 MG/ML INJECTION, TREPROSTINIL, 1 MG INJECTION, TREPROSTINIL, 1 MG INJECTION, TREPROSTINIL, 1 MG INJECTION, TREPROSTINIL, 1 MG INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED TRIAMCINOLONE ACT, PER 10MG TRIAMCINOLONE ACT, PER 10MG INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED TRIAMCINOLONE ACT, PER 10MG INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED Earliest Start Date 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 07/27/2007 01/01/2007 04/01/2008 04/01/2008 10/01/2005 11/01/2005 01/01/2005 01/09/2006 01/01/2002 04/25/2002 04/25/2002 04/25/2002 08/01/2008 07/22/2008 01/01/2003 01/01/2003 01/01/2003 09/12/2003 09/08/2003 01/01/2002 01/01/2002 07/01/2006 01/01/2002 04/25/2006 01/01/2002 03/31/2005 05/30/2005 09/26/2005 03/31/2005 11/02/2004 02/15/2006 01/01/2002 01/01/2002 01/01/2002 04/05/2004 04/05/2004 04/05/2004 04/19/2004 04/05/2004 01/18/2010 01/01/2010 01/18/2010 01/01/2002 01/01/2002 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2007 01/01/2007 01/01/2002 11/29/2007 07/22/2009 07/22/2009 02/08/2008 01/01/2006 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2010 09/30/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3301 J3301 J3301 J3301 J3301 J3302 J3302 J3302 J3302 J3302 J3302 J3302 J3302 J3302 J3302 J3302 J3302 J3302 J3303 J3303 J3303 J3303 J3303 J3303 J3303 J3303 J3305 J3305 J3310 J3315 J3315 J3315 J3315 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3350 J3355 J3355 J3355 J3355 J3355 J3355 J3355 J3357 J3357 J3360 J3360 J3360 55045324801 63370030015 63370030020 63370030025 63370030035 00463109105 38779016603 38779016604 38779016605 49452791001 49452791002 49452791003 49452791004 51552027801 51552027802 51552027803 51927337000 55553004205 00781308475 00781308571 00781308575 54643105400 54643105500 54643105600 54868334400 58016485501 58178002010 58178002101 51927235100 52544015302 52544015376 52544015402 52544015476 00406864212 10106420601 10106420605 17317059301 17317059305 17317059308 17317146601 17317146605 38779010108 38779010109 49452807001 49452807002 49452807003 51552005704 51552005706 51552005708 51927126900 53191016101 53191016105 62991138201 44087607501 44087607503 44087607504 44087615001 54569264600 55566850502 55566850506 57894006003 57894006103 00409127332 00409321302 00409321312 12/19/2013 HCPCS Description INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG INJ, TRIAMCIN HEXACETONIDE, 5MG INJ, TRIAMCIN HEXACETONIDE, 5MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG INJECTION, PERPHENAZINE, UP TO 5 MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UREA, UP TO 40 GM INJECTION, UROFOLLITROPIN, 75 IU INJECTION, UROFOLLITROPIN, 75 IU INJECTION, UROFOLLITROPIN, 75 IU INJECTION, UROFOLLITROPIN, 75 IU INJECTION, UROFOLLITROPIN, 75 IU INJECTION, UROFOLLITROPIN, 75 IU INJECTION, UROFOLLITROPIN, 75 IU INJECTION, USTEKINUMAB, 1 MG INJECTION, USTEKINUMAB, 1 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED Earliest Start Date 07/21/2006 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/29/2007 01/01/2007 01/01/2007 03/15/2004 03/15/2004 03/15/2004 01/01/2002 02/01/2006 01/01/2002 01/01/2002 08/09/2003 12/30/2004 04/01/2005 12/30/2004 04/01/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 12/04/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2012 01/01/2012 08/23/2005 05/09/2005 10/01/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2007 01/31/2008 12/31/2078 12/31/2078 12/31/2078 09/30/2006 12/31/2078 12/31/2078 02/28/2009 12/31/2078 11/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/01/1997 04/01/1997 04/01/1997 04/01/1997 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3360 J3365 J3365 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3370 J3385 00641140833 00641228941 00641228943 23490754502 38779092505 38779092508 38779092509 49452254001 49452254002 49452254003 51552102502 51552102504 51552102505 51927101400 54569535100 54868061701 54868061702 54868071600 54868232001 54868232002 54868458600 55045213303 63874022901 63874022910 66758002001 66758002002 24430100101 24430100301 00069258910 00074433201 00338355148 00338355248 00409433201 00409433249 00409650901 00409650949 00409653301 00409653349 00409653361 00409653401 00409653449 00409653501 00409653549 10139050112 23360015140 23360015250 38779027403 38779027404 38779027406 51552103601 51552103609 51927174200 62991252201 62991252202 62991252203 62991252204 63323022110 63323028420 63323029561 63323031461 63370035010 63370035015 63370035025 63370035035 54092070104 12/19/2013 HCPCS Description INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, IV, UROKINASE, 250,000 I.U. VIAL INJECTION, IV, UROKINASE, 250,000 I.U. VIAL VANCOMYCIN, PER 500, INJ INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG VANCOMYCIN, PER 500, INJ VANCOMYCIN, PER 500, INJ INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VELAGLUCERASE ALFA, 100 UNITS Earliest Start Date 01/01/2002 01/01/2002 08/05/2004 04/09/2007 04/25/2002 04/25/2002 04/25/2002 01/01/2003 01/01/2003 01/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 03/07/2002 03/07/2002 04/03/2008 01/01/2002 01/01/2002 01/01/2002 01/23/2002 03/24/2003 04/04/2008 04/04/2008 10/02/2003 10/02/2003 04/01/2007 04/07/2008 04/28/2011 01/01/2002 01/01/2002 01/01/2002 04/25/2005 08/04/2005 06/06/2005 06/03/2005 03/15/2005 04/06/2005 10/01/2007 06/08/2005 06/10/2005 03/29/2005 04/06/2005 08/19/2008 10/01/2010 10/01/2010 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/08/2003 09/15/2003 09/15/2003 09/15/2003 09/15/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2012 Latest End Date 12/31/2078 07/28/2008 07/28/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2012 02/28/2013 02/28/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3396 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3410 J3411 J3411 J3411 J3411 J3411 J3411 J3411 J3411 J3411 J3411 J3411 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3415 J3420 J3420 J3420 J3420 J3420 J3420 00078043761 00463110110 00517420125 00517560125 00517560225 00517561025 38779029804 38779029805 49452365202 49452365203 51927140000 54868023100 54868085800 55553017110 58016929901 62991203501 62991203502 63323002101 63323005101 63323005102 63370010725 63370010735 63370010750 63370010755 00463107430 51927124200 54868248901 62991206802 62991206803 62991206804 63323001302 63370048535 63370048545 63370048550 63370048553 10106334301 17317045502 17317045503 17317045505 17317045506 25332007330 33358031301 38779087304 38779087305 38779087308 38779087309 49452614001 49452614002 49452614003 51552014904 51552014905 51927109300 62991113002 62991113003 63323018001 63370047235 63370047245 63370047250 63370047253 00463101530 00463102130 00463109430 00517003125 00517003225 00517013005 12/19/2013 Earliest Start Date HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, VERTEPORFIN, 0.1 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE HCL, UP TO 25 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG THIAMINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG PYRIDOXINE HCL, 100 MG VITAMIN B-12 CYANOCOBALAMIN, VITAMIN B-12 CYANOCOBALAMIN, VITAMIN B-12 CYANOCOBALAMIN, VITAMIN B-12 CYANOCOBALAMIN, VITAMIN B-12 CYANOCOBALAMIN, VITAMIN B-12 CYANOCOBALAMIN, UP UP UP UP UP UP TO TO TO TO TO TO 1000 1000 1000 1000 1000 1000 MCG MCG MCG MCG MCG MCG 10/18/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/30/2002 04/30/2002 01/01/2002 01/01/2002 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 10/01/2007 01/01/2004 10/26/2006 10/26/2006 10/26/2006 10/26/2006 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 07/10/2007 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 01/01/2004 10/26/2006 10/26/2006 10/26/2006 10/26/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/29/2003 Latest End Date 11/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3420 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3430 J3465 J3470 J3470 J3470 J3470 J3470 J3470 J3470 J3472 J3473 J3473 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 11584102501 25332000430 25332007810 38779046803 38779046804 38779046805 38779046806 49452240002 49452240003 49452240004 51552104501 51552104509 51927166200 52637028210 52637031230 54569553300 54868076200 54868076201 55553009110 55553009130 62991103901 62991103902 62991103903 63323004401 00409915701 00409915801 00548114000 49452441001 49452441002 49452539001 49452539002 49452539003 51552106302 51927172200 51927192500 63370046210 63370046215 63370046225 00049319028 00548909000 00548909010 17478056001 60977031903 67425000101 67425000110 67425000210 67425000210 60977031903 60977031944 00406420012 00409175410 00409216802 00409216803 00409672723 00409672803 00409672903 00409672909 00409672923 00409672924 00409673013 00517260225 00517261025 00517265025 00548103400 10106250601 12/19/2013 HCPCS Description INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG VITAMIN K INJECTION PER 1MG INJ, PHYTONADIONE 1MG, VIT K PHYTONADIONE INJ, PER 1MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, VORICONAZOLE, 10 MG INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1000 INJECTION, HYALURONIDASE, RECOMBINANT, 1 USP UNIT INJECTION, HYALURONIDASE, RECOMBINANT, 1 USP UNIT INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MAGNESIUM SULFATE, PER 500 MG Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 04/25/2003 04/25/2003 04/25/2003 04/25/2003 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 12/04/2003 01/01/2002 01/01/2002 09/19/2003 01/01/2002 09/18/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2006 01/01/2006 09/30/1990 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 12/04/2003 09/08/2003 10/25/2006 10/25/2006 10/25/2006 01/01/2004 11/01/2004 04/25/2005 05/16/2007 03/30/2006 01/28/2005 01/28/2005 01/28/2005 01/01/2012 01/01/2007 04/27/2007 01/01/2002 11/27/2006 01/31/2005 10/22/2004 09/20/2005 12/01/2006 08/16/2005 09/22/2005 10/06/2005 12/01/2006 04/03/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/30/2011 07/30/2011 12/31/2078 12/31/2078 12/31/2078 10/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2010 12/31/2078 Page 1 of 1 HCPCS NDC J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3475 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 10106250605 17317034501 17317034505 17317034508 17317034601 17317034605 17317034608 17317141301 17317141303 23535060861 23535060868 49452430001 49452430002 49452430003 51927229800 51927273200 54868572400 61553042104 61553042302 63323006402 63323006410 63323006420 63323006450 00074393402 00074665106 00264194010 00264194020 00264786500 00338031802 00338069104 00338069504 00338070341 00338070348 00338070434 00338070541 00338070548 00338070948 00406683804 00406683806 00406684504 00406685804 00409151302 00409390703 00409663501 00409663601 00409665106 00409665305 00409707426 00409707514 00409707526 00409707626 00409707714 00409707726 00409711509 00409711609 10106304601 10106304605 10106305201 10106305205 17317043801 17317043805 17317043808 49072057130 49452577001 49452577002 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG MAGNESIUM SULFATE, PER 500 MG POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ POTASSIUM CHLORIDE, PER 2 MEQ Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/04/2003 12/04/2003 12/12/2006 02/01/2005 07/11/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/21/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/16/2005 11/24/2004 09/21/2005 08/09/2005 11/10/2005 08/09/2005 04/25/2005 06/08/2005 04/11/2005 02/08/2006 06/28/2005 05/04/2005 04/06/2005 06/22/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/01/2008 07/01/2007 10/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3480 J3485 J3486 J3487 J3487 J3487 J3487 J3487 J3487 J3488 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 49452577003 49452578001 49452578002 49452578003 51552006106 51552032406 51552032408 51552032409 51927109000 54868076700 54868076701 62991154901 62991154902 63323096505 63323096510 63323096515 63323096520 63323096730 00173010793 00049392083 00078059061 23155018631 25021080166 42023015101 47335003540 53150087101 00078043561 00003218710 00004003822 00004018809 00004035009 00004035239 00004038039 00005010432 00006353750 00006353904 00006409406 00006409431 00006498000 00006498100 00006499200 00006499500 00006499541 00007440106 00008092355 00008536002 00009023301 00009072809 00009077526 00009087026 00009090218 00009312403 00009337502 00009338102 00009338202 00009344703 00015710128 00015722518 00029657126 00029657131 00029657140 00029657921 00049101028 00049338225 00052027201 12/19/2013 HCPCS Description INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, ZIDOVUDINE, 10 MG INJECTION, ZIPRASIDONE MESYLATE, 10 MG ZOLDERONIC ACID PER 1MG (ZOMETA) ZOLDERONIC ACID PER 1MG (ZOMETA) ZOLDERONIC ACID PER 1MG (ZOMETA) ZOLDERONIC ACID PER 1MG (ZOMETA) ZOLDERONIC ACID PER 1MG (ZOMETA) ZOLDERONIC ACID PER 1MG (ZOMETA) INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG UNCLASSIFIED DRUGS IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 12/04/2003 01/01/2002 03/16/2007 09/15/2003 09/15/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2004 09/20/2011 03/30/2013 03/05/2013 03/05/2013 03/08/2013 05/13/2013 01/01/2008 01/03/2006 01/01/2002 02/24/2006 10/16/2002 01/19/2004 03/12/2003 01/01/2002 01/01/2002 01/01/2002 06/19/2007 06/19/2007 01/01/2002 01/01/2002 07/09/2002 07/09/2002 07/16/2002 01/27/2006 05/18/2004 06/17/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/25/2006 10/19/2005 08/10/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2012 12/31/2078 07/13/2014 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2012 12/31/2078 09/01/2010 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 00052030151 00068059701 00074116201 00074141204 00074141210 00074156010 00074161050 00074338225 00074405201 00074574922 00074744401 00085127901 00085129101 00085129701 00085129702 00085130401 00085131601 00085131602 00085132301 00085132302 00085136801 00085137001 00085137002 00186102603 00186103001 00186103002 00186103012 00186103091 00186103101 00186103301 00186103302 00186103312 00186103391 00186103501 00186103701 00186103702 00186103712 00264553532 00310030011 00310030022 00310030050 00310030061 00310030064 00310030065 00338101741 00338101948 00338105548 00338519741 00338519841 00406067252 00409115801 00409115802 00409115901 00409115902 00409116001 00409116101 00409116201 00409116202 00409116301 00409116401 00409116501 00409116502 00409141204 00409141210 00409155910 12/19/2013 HCPCS Description UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS Earliest Start Date 05/01/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/02/2004 03/07/2005 01/01/2002 02/02/2004 03/07/2005 02/02/2004 03/07/2005 01/01/2002 02/02/2004 03/07/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/18/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/01/2003 01/01/2002 07/27/2005 10/28/2005 06/29/2005 08/10/2005 04/12/2005 10/18/2004 03/08/2006 11/22/2005 03/30/2005 03/24/2006 12/08/2005 05/24/2005 06/14/2006 06/29/2006 08/22/2005 Latest End Date 12/31/2078 12/31/2078 09/01/2007 08/01/2007 04/01/2007 05/01/2007 09/01/2007 07/01/2006 03/01/2007 06/01/2006 03/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2012 04/30/2013 10/31/2012 10/31/2012 02/28/2012 04/30/2013 05/31/2013 11/30/2011 04/30/2013 03/31/2012 05/31/2013 04/30/2012 11/30/2012 12/31/2078 12/31/2078 09/30/2010 09/30/2010 10/31/2010 07/31/2010 07/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 00409155930 00409156010 00409156029 00409158210 00409158229 00409158750 00409161050 00409176102 00409338031 00409338032 00409338035 00409338049 00409338050 00409338051 00409338221 00409338222 00409338225 00409361301 00409405001 00409405101 00409405201 00409405303 00409405403 00409405503 00409419701 00409427201 00409427301 00409427401 00409434673 00409469924 00409469930 00409469933 00409469940 00409469961 00409744401 00409744501 00409744716 00409781124 00409781137 00517912025 00703285604 00703285809 00703285903 00703950303 00703951403 00703952601 00781312485 00781312495 00781312585 00781312592 00781312595 00781312646 00781312695 00781312892 00781312992 00781615395 00781912485 00781912495 00781912585 00781912595 00781912646 00781912695 00781922415 00781922492 00781922520 12/19/2013 HCPCS Description UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS Earliest Start Date 09/07/2005 08/31/2005 08/05/2005 07/22/2005 08/04/2005 01/10/2006 11/22/2005 06/06/2005 09/01/2005 11/03/2005 12/28/2005 11/29/2005 11/07/2005 10/12/2005 07/15/2005 07/18/2005 10/19/2005 01/07/2005 05/13/2005 05/31/2005 07/05/2005 05/11/2005 02/18/2005 02/24/2005 03/31/2005 04/06/2006 06/28/2006 03/31/2006 04/13/2005 03/22/2006 03/22/2006 03/22/2006 01/31/2008 12/01/2007 04/03/2006 11/10/2005 01/09/2006 08/31/2005 09/22/2005 03/12/2003 06/26/2007 06/26/2007 06/26/2007 01/01/2002 01/01/2002 01/01/2002 09/09/2005 04/27/2004 09/09/2005 02/23/2005 04/27/2004 09/09/2005 04/27/2004 04/17/2006 02/22/2006 01/01/2002 02/01/2007 02/01/2006 02/01/2007 02/01/2006 03/31/2007 02/01/2006 02/01/2007 09/18/2006 02/01/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 00781922592 03221020811 03221040711 03221041511 03221060811 03221081411 03221101611 03221122511 10019001301 10019001302 10019001303 10019001306 10019004502 10019004517 10019004603 10019004604 10019004614 10019004663 10019004701 10019004717 10019004802 10019004803 10019004814 10019004863 10019005006 10019005021 10019005036 10019005037 10019005039 10019005043 10019021301 10019021302 10019021303 10019021311 10019021320 10019021352 10019050602 10019050610 10019050645 10106108001 10139007501 10139007502 10139007505 10139007510 10139007512 10139007515 11098005001 11098005002 11098005005 11994001104 15054104005 16887021101 16887021105 17317004901 17317004904 17317004905 24208041601 25332008805 25682000101 38779000603 38779000604 38779000605 38779001501 38779001504 38779001505 12/19/2013 HCPCS Description UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS Earliest Start Date 09/18/2006 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2002 01/01/2002 01/01/2002 10/01/2002 11/01/2003 05/05/2007 01/01/2002 11/01/2003 05/05/2007 05/05/2007 11/01/2003 05/05/2007 11/01/2003 01/01/2004 05/05/2007 05/05/2007 01/01/2002 01/01/2002 05/05/2007 05/05/2007 05/05/2007 01/01/2002 09/10/2002 09/10/2002 09/10/2002 05/05/2007 05/05/2007 05/05/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/20/2006 11/20/2006 11/20/2006 11/20/2006 11/20/2006 11/20/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/01/2005 12/15/2006 12/15/2006 01/01/2002 01/01/2002 01/01/2002 06/20/2005 01/01/2002 03/26/2007 01/01/2002 01/01/2002 01/01/2002 04/26/2002 04/26/2002 04/26/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2009 04/30/2009 10/30/2009 02/28/2008 03/31/2014 03/31/2014 02/28/2014 01/31/2014 01/31/2014 02/28/2014 07/28/2009 12/31/2078 06/28/2009 03/28/2009 12/31/2078 12/31/2078 03/31/2014 11/30/2013 03/31/2014 11/30/2013 12/31/2012 12/31/2012 06/30/2009 06/30/2009 06/30/2009 06/30/2009 12/31/2078 12/31/2078 12/31/2078 05/31/2013 02/28/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2012 08/31/2012 07/31/2012 12/31/2078 12/31/2078 02/28/2010 02/28/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 38779006305 38779006308 38779006309 38779012304 38779012305 38779012308 38779012309 38779012601 38779012603 38779012604 38779012606 38779014604 38779014605 38779014608 38779014609 38779053405 38779053408 38779053409 38779065504 38779065505 38779065508 38779098904 38779098905 38779098908 38779098909 38779176400 38779176403 38779176406 38779196807 38779196809 38779210205 38779210209 39822020005 39822027702 39822027707 39822027709 44087111201 44087111301 44087111401 44087115001 44087900501 44087900506 44087903001 44087907001 49281054505 49452040901 49452040902 49452040903 49452040904 49452080001 49452080101 49452097001 49452097002 49452097003 49452107202 49452107203 49452303802 49452303803 49452303804 49452303805 49452354301 49452354302 49452472601 49452472602 49452472603 12/19/2013 HCPCS Description UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS 17P, 250MG (COMPOUNDED 250MG/ML) 17P, 250MG (COMPOUNDED 250MG/ML) UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/03/2002 04/25/2002 04/25/2002 04/25/2002 08/21/2002 08/21/2002 08/21/2002 01/28/2002 01/28/2002 01/28/2002 01/28/2002 01/28/2002 01/28/2002 01/28/2002 01/01/2002 01/01/2002 10/31/2009 10/31/2009 01/01/2002 01/01/2002 11/16/2005 02/01/2006 06/15/2004 06/15/2004 06/15/2004 11/10/2003 06/07/2004 06/07/2004 05/10/2004 05/07/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/15/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/08/2002 01/31/2002 01/31/2002 01/31/2002 01/31/2002 01/01/2007 01/01/2007 03/19/2002 03/19/2002 03/19/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 49452622204 49452622205 49452622206 50242005801 50242005804 50242008001 51479004005 51479004110 51479004115 51479004210 51479004215 51479004801 51479004901 51552003803 51552003804 51552003805 51552003806 51552013002 51552013004 51552013006 51552052902 51552052903 51552062801 51552065201 51552065202 51552065204 51552071504 51552071505 51552071506 51552073701 51552073702 51552076305 51552076307 51552088902 51552088903 51552088904 51552088909 51552102802 51552102804 51927119400 51927144900 51927159700 51927168300 51927177600 51927182900 51927195400 51927195600 51927230300 51927321300 51927340800 51927354800 51927363400 54092070001 54569326000 54569531100 54569540800 54569557800 54569562800 54569562900 54569563000 54569578100 54569586200 54868073400 54868221900 54868221901 12/19/2013 HCPCS Description UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS 17P, 250MG (COMPOUNDED 250MG/ML) 17P, 250MG (COMPOUNDED 250MG/ML) UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 10/27/2003 10/27/2003 06/30/2006 09/30/2005 09/30/2005 09/30/2005 09/30/2005 09/30/2005 09/30/2005 09/30/2005 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 01/01/2002 09/01/2003 09/01/2003 09/01/2003 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/01/2003 10/31/2009 10/31/2009 09/08/2003 09/08/2003 12/04/2003 09/08/2003 09/08/2003 09/08/2003 09/08/2003 09/08/2003 09/08/2003 01/03/2005 09/08/2003 09/08/2003 01/04/2008 07/25/2006 01/01/2002 01/01/2002 07/18/2002 07/21/2004 11/10/2004 11/10/2004 11/10/2004 03/16/2006 11/13/2006 08/27/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 06/30/2010 06/30/2010 12/31/2078 10/31/2007 03/31/2007 03/31/2012 12/31/2078 11/30/2011 02/04/2011 02/03/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 54868313400 54868313401 54868323600 54868343700 54868369400 54868369500 54868372700 54868415400 54868416900 54868419400 54868462900 54868478100 54868503600 54868503601 55045325105 55045325202 55045377305 55390002601 55390002701 55390002810 55390002910 55390004210 55390010420 55390010450 55390010499 55390010901 55390012301 55390050002 55390050005 55390050010 55390050102 55390050105 55390050110 55513017701 55513017707 55513017728 55513095401 55513095501 55513095601 58016934301 58160081511 58160081546 58160082011 58160082046 58160082111 58160082146 58160085011 58160085046 58160085611 58160085635 58160085646 58160085711 58160085746 58468015001 59148001665 61553018948 61553019048 61553019148 61553019202 61553019341 61553019448 61553022802 61570009501 61570009525 61570009625 12/19/2013 HCPCS Description UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS Earliest Start Date 01/01/2002 02/02/2007 01/02/2003 02/02/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/02/2004 01/01/2002 10/07/2003 04/24/2003 03/31/2004 06/29/2006 07/01/2006 07/01/2006 04/06/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/23/2005 06/23/2005 06/23/2005 04/08/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/23/2004 10/10/2006 10/10/2006 10/10/2006 01/01/2002 08/06/2007 06/25/2007 02/01/2007 02/01/2007 02/01/2007 03/28/2007 01/01/2002 03/20/2002 01/01/2002 01/01/2002 01/17/2002 03/30/2006 02/01/2002 05/11/2006 12/08/2006 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 02/02/2004 11/21/2007 01/09/2003 01/09/2003 01/09/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2009 03/31/2009 02/28/2009 01/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2009 07/31/2009 06/30/2009 10/31/2011 10/31/2007 10/31/2011 12/31/2078 02/28/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2010 08/31/2009 04/30/2009 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 62794025513 62794025537 62991102102 62991102104 62991113301 62991113302 62991113303 62991113304 62991135201 62991135202 62991135204 62991151301 62991151302 62991151303 62991168501 62991168502 62991168503 62991250101 62991250102 63275620001 63275620006 63275620007 63275620009 63323026920 63323026927 63323026950 63323026957 63323026965 63323026967 63323028202 63323028204 63323028206 63323028260 63323032930 63323038020 63323038120 63323038510 63323038620 63323039050 63323073804 63323073820 63323073912 63370002206 63370002209 63370002215 63370003125 63370003135 63370003145 63370003210 63370003215 63370003225 63370003235 63370003435 63370003445 63370003450 63370009125 63370009135 63370009145 63370010910 63370010916 63370015225 63370015235 63370015245 63370096804 63370096806 12/19/2013 HCPCS Description UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS DRUGS Earliest Start Date 06/21/2004 06/21/2004 01/01/2002 09/15/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2007 09/15/2003 09/15/2003 09/15/2003 09/01/2002 09/01/2002 09/01/2002 09/15/2003 09/15/2003 01/01/2002 12/03/2002 12/03/2002 12/03/2002 02/21/2008 01/15/2008 04/28/2008 03/05/2008 03/06/2008 02/01/2008 05/11/2007 05/11/2007 05/11/2007 05/11/2007 04/23/2004 01/12/2004 01/12/2004 08/13/2007 08/13/2007 01/12/2004 01/01/2002 01/01/2002 05/14/2002 12/19/2003 12/19/2003 12/19/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/12/2004 07/12/2004 07/12/2004 07/12/2004 07/12/2004 07/12/2004 01/01/2007 01/01/2007 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 Latest End Date 08/31/2007 08/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3490 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3520 J3535 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J3590 J7030 J7030 J7030 J7030 J7030 J7030 J7030 J7030 J7030 J7030 J7040 J7040 J7040 J7040 J7040 J7040 J7040 63459030042 63459039120 66758002501 66758002502 66758002503 66758002504 67871772902 68135002001 00074694003 00406139504 00409694003 10106899401 17317082901 17317082905 17317082908 17317148501 17317148504 17317148505 17317156501 17317156505 17317156508 49452270201 49452270202 49452270203 51552058806 51927131700 62991202602 62991202603 62991202604 63370043235 63370043250 67457014720 54868551100 00944417505 00944417510 13533063601 13533063602 13533063603 13533063605 49999042505 54569473900 54868228901 59730420201 59730420301 59730420401 59730420501 60492005102 60492005202 00264400055 00264780000 00338004904 00409488820 00409798302 00409798303 00409798309 00409798348 54868071000 54868071004 00264400155 00264780000 00264780010 00338004403 00338004903 00409488820 00409798302 12/19/2013 HCPCS Description UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS UNCLASSIFIED DRUGS EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG EDETATE DISODIUM, PER 150 MG DRUG ADMINISTERED THROUGH A METERED DOSE INHALER UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION , 1000 CC NORMAL SALINE INF 1000ML NORMAL SALINE INF 1000ML INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) NORMAL SALINE INF 500ML INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) NORMAL SALINE INF 500ML NORMAL SALINE INF 500ML Earliest Start Date 06/12/2006 03/31/2008 12/18/2003 12/18/2003 12/18/2003 12/18/2003 10/01/2005 06/05/2005 01/01/2002 01/01/2002 10/17/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/11/2002 01/11/2002 01/01/2002 09/01/2003 12/04/2003 01/01/2002 01/01/2002 09/15/2003 10/24/2006 10/24/2006 07/01/2005 10/21/2008 06/28/2007 06/28/2007 10/14/2006 01/18/2006 01/18/2006 01/18/2006 07/06/2004 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/03/2005 01/01/2004 10/01/2007 10/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2006 01/01/2006 01/01/2006 02/07/2005 04/14/2006 01/01/2002 12/15/2006 01/01/2002 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2006 01/01/2006 Latest End Date 05/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/01/2008 12/31/2078 09/01/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2009 06/30/2009 12/31/2078 12/31/2078 06/30/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7040 J7040 J7040 J7040 J7040 J7042 J7042 J7042 J7042 J7042 J7042 J7042 J7042 J7042 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7050 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 00409798303 00409798309 00409798330 00409798355 54868071001 00264761000 00264761010 00264761020 00338008902 00338008903 00338008904 00409794102 00409794103 00409794109 00264180032 00264400255 00264780000 00264780020 00338004402 00338004901 00338004902 00338004911 00338004918 00338004938 00338004948 00338055318 00338630402 00409158301 00409158302 00409158411 00409488820 00409710102 00409710167 00409798302 00409798303 00409798309 00409798353 00409798361 00409798423 00409798437 54868071003 54868071006 63323018600 00074710013 00074792255 00264110155 00264110255 00264110755 00264151031 00264151032 00264151036 00264751000 00264751010 00264751020 00338001602 00338001603 00338001701 00338001702 00338001703 00338001704 00338001710 00338001711 00338001718 00338001731 00338001738 12/19/2013 HCPCS Description INFUSION, NORMAL SALINE SOLUTION, STERILE (500 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC NORMAL SALINE, IV, PER 250 ML INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC INFUSION, NORMAL SALINE SOLUTION , 250 CC D5W 500ML 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) ML=1 ML=1 ML=1 ML=1 ML=1 UNIT) UNIT) UNIT) UNIT) UNIT) Earliest Start Date 01/05/2005 01/01/2006 04/14/2006 04/11/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/27/2006 09/20/2005 08/08/2005 01/01/2002 01/01/2002 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/1991 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/19/2010 07/20/2005 09/14/2005 09/16/2005 01/01/2006 07/08/2005 08/24/2005 07/01/2005 01/01/2006 01/01/2002 09/30/2005 06/17/2005 05/18/2005 07/15/2005 12/12/2006 01/02/2007 01/01/2002 09/30/1990 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2013 12/31/2078 12/31/2078 10/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/01/2011 12/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/01/2007 12/31/2014 12/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7060 J7100 J7100 J7100 J7110 J7110 J7110 J7110 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 J7120 00338001741 00338001748 00338055111 00338055118 00338634602 00409108051 00409108201 00409108251 00409152201 00409152202 00409152203 00409152301 00409152311 00409710002 00409710066 00409710067 00409792202 00409792203 00409792209 00409792230 00409792248 00409792253 00409792255 00409792261 00409792313 00409792320 00409792323 00409792336 00409792337 54868029601 54868029602 54868029604 00338027003 00409741803 00409741903 00074150703 00264196010 00338026503 00409150503 00264350055 00264350155 00264351055 00264351155 00264775000 00264775010 00264775020 00264775100 00264775110 00338011702 00338011703 00338011704 00338012503 00338012504 00338081104 00338081504 00338630702 00409711109 00409711309 00409792903 00409792909 00409795302 00409795303 00409795309 00409795330 00409795348 12/19/2013 HCPCS Description 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) INFUSION, DEXTRAN 40, 500 ML INFUSION, DEXTRAN 40, 500 ML INFUSION, DEXTRAN 40, 500 ML INFUSION, DEXTRAN 75, 500 ML INFUSION, DEXTRAN 75, 500 ML INFUSION, DEXTRAN 75, 500 ML INFUSION, DEXTRAN 75, 500 ML RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 RINGERS LACTATE INFUSION, UP TO 1000 CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/01/2007 03/24/2006 04/25/2005 03/29/2006 04/11/2005 03/09/2005 06/16/2005 09/16/2005 07/27/2005 07/22/2005 08/17/2005 09/14/2005 04/05/2005 02/25/2005 02/21/2005 04/14/2006 04/14/2006 09/01/2005 10/31/2006 08/05/2005 06/09/2005 06/17/2005 07/15/2005 04/05/2005 03/16/2005 01/01/2002 01/01/2002 12/12/2006 01/01/2002 02/14/2006 08/09/2005 01/01/2002 01/01/2002 01/01/2002 12/29/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/17/2007 08/05/2005 02/21/2005 06/09/2005 02/07/2005 03/09/2005 05/20/2005 05/18/2005 04/14/2006 04/14/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/01/2011 12/31/2078 12/31/2078 12/31/2078 12/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2008 12/31/2078 12/31/2078 10/01/2006 09/30/2009 08/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7120 J7185 J7185 J7185 J7185 J7186 J7186 J7186 J7186 J7186 J7186 J7187 J7187 J7187 J7187 J7187 J7187 J7188 J7188 J7188 J7188 J7188 J7188 J7189 J7189 J7189 J7189 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7190 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 54868010200 58394001201 58394001301 58394001401 58394001501 68516460001 68516460002 68516460101 68516460201 68516460302 68516460402 00053761505 00053761510 00053761520 00053762005 00053762010 00053762020 00053761505 00053761510 00053761520 00053762005 00053762010 00053762020 00169705001 00169706001 00169706101 00169706201 00026066520 00026066530 00026066550 00053765601 00053765602 00053765604 00053765605 00944130110 00944130210 00944130310 00944130410 00944293501 00944293502 00944293503 00944293504 13533066520 13533066530 13533066550 52769046001 00026037220 00026037230 00026037250 00026037920 00026037930 00026037950 00026378660 00026379660 00053813001 00053813002 00053813004 00944283110 00944283210 00944283310 00944284110 00944293801 00944293802 00944293803 00944294001 12/19/2013 HCPCS Description RINGERS LACTATE INFUSION, UP TO 1000 CC FACTOR VIII (ANIT-HEMOPHILIC FACTOR, RECOMBINANT), PER IU FACTOR VIII (ANIT-HEMOPHILIC FACTOR, RECOMBINANT), PER IU FACTOR VIII (ANIT-HEMOPHILIC FACTOR, RECOMBINANT), PER IU FACTOR VIII (ANIT-HEMOPHILIC FACTOR, RECOMBINANT), PER IU INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IU INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IU INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IU INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IU INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IU INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IU FACTOR VIIA (ANIT-HEMOPHILIC FACTOR, RECOMBINANT), PER 1MCG FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICR FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICR FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICR FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I. U. , FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. Earliest Start Date 12/11/2006 01/01/2010 01/01/2010 01/01/2010 01/01/2010 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 02/15/2006 02/15/2006 02/15/2006 01/01/2006 01/01/2006 01/01/2006 08/04/2008 01/01/2006 01/01/2006 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/26/2004 02/01/2006 02/01/2006 02/01/2006 02/01/2006 01/01/2002 04/17/2006 04/17/2006 04/17/2006 11/01/2007 11/01/2007 11/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2006 01/01/2006 01/01/2006 07/02/2007 07/02/2007 01/01/2002 01/01/2002 01/01/2002 10/05/2007 10/05/2007 10/05/2007 05/25/2011 01/01/2002 01/01/2002 01/01/2002 07/28/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/12/2011 11/17/2011 03/10/2012 12/31/2078 12/31/2078 12/31/2078 09/12/2011 11/17/2011 03/10/2012 12/31/2078 12/31/2078 12/31/2078 01/31/2015 03/31/2011 03/31/2011 02/28/2011 08/16/2006 04/25/2007 02/22/2007 12/31/2078 12/31/2078 11/05/2012 10/28/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/27/2010 12/31/2078 10/08/2010 11/28/2012 11/08/2012 03/31/2013 12/30/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/15/2011 02/17/2012 02/24/2012 11/02/2012 04/26/2013 04/26/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7192 J7193 J7193 J7193 J7194 J7194 J7194 J7194 J7195 J7195 J7195 J7195 J7195 J7195 J7195 J7197 J7197 J7198 J7198 J7198 J7300 J7300 J7302 00944294002 00944294003 00944294004 00944294010 00944294110 00944294210 00944294310 00944294410 00944294510 00944294610 58394000502 58394000504 58394000602 58394000702 58394001102 58394001104 00053766802 00053766804 68516360002 00944058101 64193024402 68516320002 68516320003 58394000101 58394000106 58394000201 58394000206 58394000301 58394000306 58394000802 13533060320 13533060330 64193022203 64193022204 64193022205 51285020401 51285020402 50419042101 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) FACTOR IX, COMPLEX, PER I.U. FACTOR IX, COMPLEX, PER I.U. FACTOR IX, COMPLEX, PER I.U. FACTOR IX, COMPLEX, PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. ANTITHROMBIN III (HUMAN), PER I.U. ANTITHROMBIN III (HUMAN), PER I.U. ANTI-INHIBITOR, PER I.U. ANTI-INHIBITOR, PER I.U. ANTI-INHIBITOR, PER I.U. INTRAUERINE COPPER CONTRACEPTIVE INTRAUERINE COPPER CONTRACEPTIVE LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, J7303 J7303 J7307 J7307 J7308 J7308 J7309 J7310 J7311 J7317 J7317 J7317 J7317 J7317 J7317 J7317 J7321 J7321 J7321 J7321 J7321 J7321 J7321 J7321 J7321 J7322 00052027301 00052027303 00052027201 00052027401 67308010101 67308010106 00299630002 24208041201 24208041601 49452354301 49452354302 62991135201 62991135202 62991135204 63370010910 63370010916 08024072412 08024072420 08363776101 08363776501 18837026502 21695037402 35356003601 35356003602 35356021901 21695031303 HORMONE CONTAINING VAGINAL RING HORMONE CONTAINING VAGINAL RING ETONOGESTREL IMPLANT SYSTEM ETONOGESTREL IMPLANT SYSTEM AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SIN AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SIN METHYL AMINOLEVULINATE (MAL) FOR TOPICAL ADMINISTRATION, 16. GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC 12/19/2013 HCPCS Description Earliest Start Date Latest End Date 01/01/2006 01/01/2006 01/01/2007 09/01/2011 01/01/2003 01/01/2003 01/01/2012 07/26/2005 01/01/2007 01/01/2003 01/01/2003 01/01/2003 01/01/2003 09/15/2003 10/24/2006 10/24/2006 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/10/2008 01/10/2008 06/05/2008 01/01/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/28/2003 07/28/2003 07/28/2003 04/17/2006 01/22/2007 01/22/2007 01/22/2007 01/22/2007 01/22/2007 07/05/2007 11/02/2004 03/26/2008 11/02/2004 11/02/2004 11/02/2004 03/26/2008 01/01/2002 01/01/2002 07/25/2003 01/01/2002 01/01/2002 07/25/2003 07/25/2003 01/01/2002 06/28/2007 01/01/2002 06/28/2007 01/01/2002 06/28/2007 06/28/2007 10/14/2006 10/14/2006 08/20/2004 01/01/2002 02/01/2006 01/01/2007 01/01/2007 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2011 12/31/2078 12/31/2078 12/31/2078 01/31/2011 12/31/2078 01/07/2013 04/19/2011 12/31/2078 09/30/2012 12/09/2010 01/25/2011 11/30/2011 12/31/2013 10/31/2011 12/31/2013 05/31/2012 04/30/2013 12/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2011 12/31/2078 10/31/2016 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 30170000001 DERMAL AND EPIDERMAL TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT 01/01/2002 12/31/2078 08541000101 08121860047 08121860055 08121860204 08121860404 08121860407 08121860505 08121860510 08121860530 03221020811 03221040711 03221041511 03221060811 03221081411 03221101611 03221122511 08478400402 08478400405 08478400406 08478400408 08478401402 08478401405 08478401406 08478401408 08478800402 08478800405 08478800406 08478800408 08533649501 08533649503 08533649504 08533649506 08533601002 08533601004 08533601005 08533601006 08533601007 08533601008 08533601009 08533601010 08533601012 08533601013 08533601014 08533602002 08533602003 08533602005 08533603001 08533603002 08533603003 08533607009 08533607440 08533607812 08533607880 07/10/2006 01/01/2005 02/03/2005 01/01/2005 01/01/2005 06/30/2005 01/01/2005 01/01/2005 01/04/2005 08/01/2007 08/01/2007 08/01/2007 08/01/2007 08/01/2007 08/01/2007 08/01/2007 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 HCPCS NDC J7322 J7322 J7322 J7322 J7322 J7322 J7323 J7324 J7340 35356003401 35356003403 54868421900 58468009001 66267092103 68115053503 55566410001 59676036001 09978000199 J7340 J7342 J7344 J7344 J7344 J7344 J7344 J7344 J7344 J7344 J7345 J7345 J7345 J7345 J7345 J7345 J7345 J7347 J7347 J7347 J7347 J7347 J7347 J7347 J7347 J7347 J7347 J7347 J7347 J7348 J7348 J7348 J7348 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 J7349 12/19/2013 HCPCS Description HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJE HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJ DERMAL AND EPIDERMAL TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL DERMAL TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENG (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITH (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITH (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITH (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITH (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITH (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITH (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITH (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHO 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7500 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7501 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7502 J7504 J7505 J7506 00054408425 00054808425 00378100501 00406200301 00781507501 12280013930 23490511009 51079062006 52959007900 54868092101 54868092102 54868092104 54868531000 54868531001 54868531002 54868531003 54868531004 55045347101 57866902101 65483059010 65649023141 65649024141 66479030110 68084022901 68382000301 68382000305 38779031203 38779031204 38779031206 49452078301 49452078302 49452078303 51552077902 51552077904 51552077905 51927225800 55390060020 63370002510 63370002515 63370002525 63370002535 00074646332 00074647932 00074726950 00078011022 00078024015 00078024115 00078024161 00078024815 00078027422 00172731246 00172731320 00185093330 00591222315 00591222455 50111088542 50111092043 54868552200 60432014050 60505013400 60505035401 62584082721 00009722402 59676010101 00054001720 12/19/2013 HCPCS Description AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG AZATHIOPRINE, PARENTERAL, 100 MG CYCLOSPORINE, 100MG, ORAL CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, 100MG, ORAL CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG CYCLOSPORINE, ORAL, 100 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, MUROMONAB-CD3, PARENTERAL, 5 MG PREDNISONE, ORAL, PER 5MG Earliest Start Date 01/01/2002 01/01/2002 12/22/2009 07/02/2007 04/04/2003 04/21/2005 04/30/2007 08/04/2010 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/23/2005 05/23/2005 09/22/2005 02/23/2006 02/28/2006 03/01/2006 04/15/2002 01/01/2002 10/31/2003 10/31/2003 09/26/2006 03/14/2008 05/01/2007 05/01/2007 01/01/2002 01/01/2002 01/01/2002 01/24/2002 01/24/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2007 01/01/2002 01/18/2002 01/01/2002 01/01/2007 01/01/2002 01/05/2012 01/01/2002 01/01/2002 04/14/2005 04/14/2005 01/01/2002 12/23/2008 12/23/2008 01/25/2002 01/01/2002 02/10/2006 09/28/2004 05/17/2002 08/01/2005 10/19/2006 01/01/2002 01/01/2002 12/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/24/2012 12/31/2078 02/29/2012 12/31/2078 12/31/2078 09/30/2011 12/31/2078 07/31/2011 12/31/2078 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 00054001725 00054001729 00054001820 00054001825 00054001829 00054001920 00054001925 00054372144 00054372250 00054372263 00054472825 00054472831 00054474125 00054474131 00054474225 00054872216 00054872425 00054873925 00054874025 00143142501 00143147301 00143147310 00143147501 00143147510 00143147701 00143147705 00143147710 00182020189 00182108689 00182133489 00259036421 00259038948 00259039021 00259039148 00463614010 00463614110 00463615510 00591505201 00591505210 00591544201 00591544205 00591544210 00591544301 00591544305 00591544310 00603533521 00603533532 00603533621 00603533715 00603533721 00603533731 00603533732 00603533815 00603533821 00603533828 00603533831 00603533832 00603533921 00603533928 00603533932 00677011701 00677011710 00677042701 00677042705 00677042710 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 01/01/2005 12/01/2004 09/07/2004 10/14/2004 10/08/2004 09/24/2004 08/10/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/09/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/03/2005 01/03/2005 01/03/2005 08/20/2003 01/16/2003 08/20/2003 01/16/2003 03/06/2003 01/30/2003 01/30/2003 04/02/2003 01/30/2003 09/10/2003 09/10/2003 09/10/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2009 03/31/2010 05/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2009 11/30/2009 02/28/2010 02/28/2010 12/31/2009 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 00677069801 00677069805 00677069810 10768708501 10768728301 10768728302 10768728303 10768728304 10768773301 10768773302 10768773303 10768773304 16590032610 16590032620 16590032621 16590032630 16590032645 16590032660 16590040410 16590040420 16590040421 16590040430 16590040445 18837026721 18837026730 18837026748 18837035310 18837035330 21695030620 21695030621 21695030628 21695030630 21695030642 21695030710 21695030715 21695030718 21695030720 21695030721 21695030730 21695058005 21695076548 23490111302 23490111303 23490615701 23490615702 23490615703 23490615704 23490615705 23490615706 23490615707 23490615708 23490615800 23490615801 23490615802 23490615803 23490615804 23490615805 23490615807 23490615808 23490615809 23490615901 23490615902 23490615903 23490615904 23490615905 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 05/12/2006 05/12/2006 05/12/2006 05/12/2006 05/12/2006 05/12/2006 05/12/2006 05/12/2006 05/12/2006 06/01/2006 06/01/2006 06/01/2006 06/01/2006 06/01/2006 11/01/2007 06/01/2006 06/01/2006 06/01/2006 06/01/2006 06/01/2006 02/15/2008 08/01/2007 02/15/2008 09/24/2008 05/22/2008 04/01/2007 04/01/2007 04/01/2007 04/01/2007 04/01/2007 02/01/2007 09/03/2008 04/01/2007 07/27/2007 08/14/2008 02/01/2007 07/25/2007 06/09/2008 10/03/2006 09/21/2006 02/07/2007 02/07/2007 02/07/2007 04/09/2007 02/07/2007 11/30/2007 02/07/2007 04/09/2007 04/09/2007 02/07/2007 02/07/2007 02/07/2007 02/07/2007 10/11/2007 04/09/2007 04/09/2007 10/11/2007 02/07/2007 02/07/2007 02/07/2007 02/07/2007 11/30/2007 Latest End Date 02/28/2010 01/31/2010 02/28/2010 12/31/2078 11/01/2008 11/01/2008 09/01/2009 11/01/2010 11/01/2008 11/01/2008 09/01/2009 11/01/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 23490615906 23490785400 33358029212 33358029215 33358029221 33358029230 33358029278 33358029320 33358029330 33358029340 33358029415 33358029420 33358029430 33358029440 33358029460 38779015403 38779015404 38779015405 38779015408 38779015409 45802030321 45802030367 45802073321 45802073367 49452600001 49452600002 49452600003 49999000800 49999000805 49999000820 49999000830 49999000840 49999000855 49999002805 49999002812 49999002814 49999002815 49999002820 49999002821 49999002828 49999002830 49999002840 49999002848 49999002850 49999002860 49999002890 49999011000 49999011006 49999011007 49999011010 49999011012 49999011014 49999011015 49999011018 49999011020 49999011021 49999011030 49999039021 49999043703 51079002217 51079002219 51079003217 51079003219 51079003317 51079003319 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 11/30/2007 11/30/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 03/07/2002 01/01/2002 01/01/2002 08/26/2002 08/26/2002 12/12/2007 12/12/2007 12/12/2007 12/12/2007 01/01/2002 01/01/2002 01/01/2002 12/01/2003 05/16/2008 07/16/2002 07/06/2004 01/27/2006 08/28/2002 03/13/2008 07/16/2002 01/27/2006 07/11/2002 07/16/2002 08/08/2008 07/01/2005 07/11/2002 07/16/2002 07/06/2004 07/16/2002 03/30/2005 03/30/2005 07/06/2004 08/27/2002 04/06/2005 07/06/2004 07/06/2004 07/06/2004 03/27/2006 10/15/2004 07/11/2002 02/24/2005 03/26/2003 06/09/2004 08/12/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2011 12/31/2011 11/30/2011 11/30/2011 08/31/2011 08/31/2011 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 51552002801 51552002802 51552002804 51552002805 51655002024 51655002052 51655002053 51655002080 51655008624 51655008627 51655008651 51655008724 51655008728 51655008749 51927143500 51991045801 51991045810 52959012600 52959012605 52959012607 52959012610 52959012612 52959012615 52959012618 52959012620 52959012621 52959012625 52959012630 52959012637 52959012640 52959012642 52959012644 52959012645 52959012650 52959012660 52959012700 52959012707 52959012710 52959012712 52959012715 52959012718 52959012720 52959012721 52959012725 52959012730 52959012737 52959012742 52959022000 52959022010 52959022020 52959022021 52959022030 52959022036 52959022040 52959022060 52959022075 53489013801 53489013810 53489013901 53489013905 53489013910 53489014001 53489014005 53489014010 54569033000 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 01/01/2002 09/01/2003 09/01/2003 09/01/2003 01/01/2002 01/01/2002 01/01/2002 06/22/2005 01/01/2002 01/01/2002 06/22/2005 01/01/2005 06/22/2005 06/22/2005 09/08/2003 01/16/2006 01/16/2006 01/01/2002 11/06/2002 11/06/2002 08/19/2003 01/01/2002 01/01/2002 01/15/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/18/2007 01/01/2002 01/01/2002 03/01/2004 09/19/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/18/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/19/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2012 03/31/2012 04/30/2012 04/30/2012 01/31/2012 04/30/2012 04/30/2012 01/31/2012 12/31/2078 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 54569033001 54569033003 54569033004 54569033007 54569033100 54569033101 54569033102 54569033104 54569033105 54569033107 54569033108 54569033201 54569033202 54569033203 54569033205 54569033209 54569033300 54569304300 54569304301 54569304302 54569304305 54569304306 54569330200 54569330201 54569341300 54569402604 54569584000 54569584100 54569591100 54868025801 54868025802 54868025804 54868025805 54868025806 54868025808 54868025809 54868083600 54868083602 54868083603 54868083604 54868083605 54868083607 54868083608 54868090800 54868090801 54868090802 54868090803 54868090804 54868092301 54868111901 54868111902 54868111903 54868111904 54868111905 54868118300 54868118301 54868118302 54868118303 54868118307 54868118308 54868118309 54868323400 54868409500 54868409600 54868521300 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/07/2006 01/01/2002 01/01/2002 01/01/2002 08/24/2010 10/10/2006 10/10/2006 05/10/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/14/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/10/2005 02/16/2006 05/16/2006 02/06/2007 01/01/2002 01/01/2002 12/09/2002 12/09/2002 06/01/2004 10/05/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/19/2003 08/15/2005 01/01/2002 04/23/2002 11/27/2002 01/25/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 54868523000 55045126000 55045126009 55045144401 55045144402 55045144403 55045144404 55045144407 55045144408 55045148001 55045148002 55045148005 55045148006 55045148007 55045148008 55045148009 55045153301 55045153303 55045153306 55045153307 55045153308 55045153309 55045296301 55045296302 55045328103 55045328104 55289033005 55289033007 55289033010 55289035205 55289035207 55289035209 55289035210 55289035212 55289035214 55289035215 55289035220 55289035221 55289035230 55289037301 55289037312 55289037330 55289037336 55289037342 55289037346 55289037355 55289037360 55289037372 55289043820 55289043821 55289043830 55289043836 55289043838 55289043840 55289043842 55289043850 55289043860 55887064315 55887064321 55887064330 55887064340 55887064342 55887064350 55887064360 55887064390 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 02/25/2005 12/06/2004 01/01/2003 12/06/2004 05/01/2005 01/01/2004 01/01/2003 01/01/2003 01/01/2003 01/01/2003 12/06/2004 12/06/2004 12/06/2004 01/01/2003 01/01/2003 01/01/2003 05/01/2004 01/01/2003 01/01/2003 01/01/2003 01/01/2003 01/01/2003 12/06/2004 12/06/2004 12/20/2004 02/11/2005 04/25/2008 09/16/2008 01/01/2002 05/01/2008 03/01/2004 01/01/2002 01/01/2002 05/01/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/13/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/18/2008 01/01/2002 03/05/2002 04/01/2004 01/01/2006 04/01/2004 01/01/2006 04/01/2007 04/01/2007 04/01/2004 04/01/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 55887069621 55887077001 55887077015 55887077020 55887077021 55887077030 55887077039 55887077050 55887077060 55887079618 55887079620 55887079621 55887079630 55887079690 57866432401 57866432404 57866432405 57866432501 57866432502 57866432503 57866432507 57866432508 57866432601 57866432602 57866432604 57866432605 57866432607 57866432608 57866432702 58016012612 58016021600 58016021610 58016021612 58016021614 58016021615 58016021620 58016021621 58016021622 58016021624 58016021628 58016021630 58016021632 58016021640 58016021642 58016021650 58016021660 58016021684 58016021690 58016021700 58016021705 58016021707 58016021710 58016021712 58016021715 58016021716 58016021718 58016021720 58016021721 58016021722 58016021723 58016021724 58016021728 58016021730 58016021740 58016021760 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 01/01/2002 01/01/2007 04/01/2007 04/01/2007 06/30/2003 04/01/2007 04/01/2007 04/01/2007 04/01/2007 01/01/2007 01/01/2006 04/01/2004 04/01/2004 01/01/2007 04/15/2002 04/15/2002 10/01/2003 04/15/2002 04/15/2002 04/15/2002 11/01/2005 01/02/2006 10/01/2003 04/15/2002 04/15/2002 10/01/2003 10/01/2003 11/01/2005 10/01/2003 01/01/2002 01/01/2002 01/01/2007 03/22/2002 03/22/2002 01/01/2002 03/22/2002 01/01/2002 01/01/2007 03/22/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2002 01/01/2007 01/01/2007 03/21/2002 01/01/2007 03/21/2002 03/21/2002 03/21/2002 01/01/2002 01/01/2002 03/21/2002 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 58016021800 58016021820 58016021821 58016021824 58016021830 58016021833 58016021836 58016021840 58016021850 58016021855 58016021860 58016021869 58016021890 58016483201 58864036220 58864036256 58864042315 58864042320 58864042330 58864042340 58864042409 58864042414 58864042420 58864042430 59746000706 59746000710 59746000806 59746000810 59746017106 59746017110 59746017206 59746017210 59746017306 59746017309 59746017310 59746017506 59746017509 59746017510 60760000221 60760013830 60760063028 62991120601 62991120602 63370019415 63370019425 63370019435 63370019445 63370019450 63629157901 63629157902 63629157903 63629158701 63629158702 63629158703 63629158704 63629160501 63629160502 63629160503 63629160504 63629160505 63739020710 63739020715 63739020810 63739020815 63739020910 12/19/2013 HCPCS Description PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, PREDNISONE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG 5MG Earliest Start Date 01/01/2002 03/22/2002 01/01/2002 03/22/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 05/31/2005 02/01/2006 03/01/2004 03/01/2004 01/01/2005 06/01/2005 01/01/2002 07/01/2004 01/01/2002 03/02/2004 01/01/2005 03/02/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/21/2005 10/21/2005 08/03/2007 08/03/2007 08/03/2007 08/03/2007 08/03/2007 08/03/2007 08/03/2007 08/03/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/12/2004 07/12/2004 07/12/2004 07/12/2004 07/12/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 03/01/2007 06/09/2004 03/01/2007 06/09/2004 03/01/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2012 12/31/2078 03/31/2012 12/31/2078 12/31/2011 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 63739020915 63739052010 63874032701 63874032702 63874032710 63874032712 63874032714 63874032715 63874032718 63874032719 63874032720 63874032721 63874032724 63874032725 63874032728 63874032730 63874032732 63874032740 63874032742 63874032750 63874032760 63874037301 63874037302 63874037310 63874037315 63874037320 63874037321 63874037330 63874037333 63874037336 63874037340 63874037350 63874037360 63874039201 63874039202 63874039206 63874039210 63874039214 63874039215 63874039220 63874039221 63874039224 63874039228 63874039230 63874039240 66267017115 66267017120 66267017121 66267017130 66267017140 66267017142 66267017210 66267017215 66267017220 66267017230 66267017320 66267017330 66267017340 66267017342 66267017360 66267094821 66336005810 66336005812 66336005820 66336005821 12/19/2013 HCPCS Description PREDNISONE, ORAL, PER 5MG PREDNISONE ORAL PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG Earliest Start Date 06/09/2004 02/14/2011 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/01/2002 04/04/2002 01/01/2002 01/01/2002 01/01/2002 04/04/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/04/2002 01/01/2002 01/01/2002 03/24/2003 01/01/2002 01/01/2002 10/22/2004 11/04/2005 10/22/2004 10/22/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7506 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7507 J7509 J7509 J7509 J7509 J7509 J7509 66336005830 66336005860 66336009410 66336009418 66336009420 66336009430 66336051510 66336051521 66336051530 66336051540 68115028910 68115028921 68115028930 68115028942 68115029015 68115029020 68115029030 68115029100 68115029121 68115029130 68115094721 68387024010 68387024025 68387024115 00078061605 00078061705 00078061805 00378204501 00378204601 00378204605 00378204701 00469060773 00469061711 00469061773 00469065711 00469065773 00591335901 00781210201 00781210301 00781210401 16729004101 16729004301 21695017000 50742020801 51079081820 51927355700 55111052501 55111052601 55111052701 62175038137 62991266401 62991266402 62991266403 62991266404 63275995801 63275995802 63275995806 63275995807 66105054910 00009002201 00009004902 00009005602 00009005603 00009005604 00009005605 12/19/2013 HCPCS Description PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG PREDNISONE, ORAL, PER 5MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG TACROLIMUS, ORAL, PER 1 MG METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER 4 4 4 4 4 4 MG MG MG MG MG MG Earliest Start Date 04/16/2002 10/22/2004 10/22/2004 10/22/2004 10/22/2004 10/22/2004 10/22/2004 10/22/2004 10/22/2004 10/22/2004 09/28/2004 10/26/2004 05/05/2004 01/05/2004 01/05/2004 09/28/2004 10/26/2004 06/08/2004 10/26/2004 01/05/2004 05/04/2004 05/29/2008 03/26/2004 07/23/2008 02/07/2012 02/07/2012 02/07/2012 09/23/2010 09/23/2010 07/13/2011 09/23/2010 01/01/2002 01/01/2002 02/13/2002 01/01/2004 01/01/2004 07/06/2010 08/10/2009 08/10/2009 08/10/2009 09/30/2011 09/30/2011 12/15/2006 10/01/2012 08/06/2013 01/01/2004 05/14/2010 05/14/2010 05/14/2010 09/28/2012 10/01/2007 10/01/2007 10/01/2007 10/01/2007 09/01/2004 09/01/2004 09/01/2004 09/01/2004 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/14/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2008 12/31/2078 12/30/2007 Page 1 of 1 HCPCS NDC J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 J7509 00009007301 00009017601 00555030102 00555030138 00591079001 00603459315 00603459321 00781502201 00781502207 00904217519 10544032221 16590014921 18837008621 21695008021 23490191102 23490590201 33261033521 33358024121 35356019421 38779014204 38779014206 49452468601 49452468602 49452468603 49884049059 49999015321 51552060302 51991018801 51991018831 52959010000 54569032700 54569103600 54868077601 54868291300 54868291301 54868291302 54868495200 54868495201 54868662401 55045125909 55045181103 55045181108 55045351301 55289064930 55289064998 55887095321 57866403701 57866710001 58016200101 58016200401 58016471901 59746000103 59746000106 59746000204 59746000314 59746001504 59762332701 59762332702 63739016110 63739016115 63874041321 66267096121 66993084002 66993084021 66993084225 12/19/2013 HCPCS Description METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER PER 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 01/01/2002 01/01/2002 02/05/2002 04/10/2002 01/01/2002 01/01/2002 01/01/2002 04/04/2003 04/04/2003 01/01/2002 01/11/2008 01/01/2006 06/01/2007 01/01/2007 10/03/2006 02/07/2007 01/15/2008 07/10/2007 05/16/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/03/2002 09/01/2003 03/10/2003 11/05/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/29/2003 10/30/2003 10/30/2003 01/01/2002 01/01/2003 12/06/2004 12/06/2004 06/23/2006 10/15/2003 01/01/2002 01/01/2002 04/15/2002 01/22/2008 10/01/2006 01/01/2002 02/16/2005 01/01/2002 01/01/2002 09/24/2007 07/20/2007 07/20/2007 01/01/2002 01/01/2002 02/27/2007 08/04/2003 01/01/2002 01/01/2002 01/21/2003 01/21/2003 04/29/2004 Latest End Date 12/31/2078 12/31/2078 02/29/2012 07/31/2012 03/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/29/2008 03/31/2008 06/30/2012 12/01/2008 12/31/2078 12/31/2078 05/31/2009 11/30/2009 02/28/2010 Page 1 of 1 HCPCS NDC J7509 J7509 J7509 J7509 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 67253036010 67253036021 68115096021 68387017001 00093611816 00093611887 00121068705 00121068708 00121068716 00121075908 00223151201 00463607110 00591021702 00591505901 00603156756 00603156758 17317044702 17317044703 17317047708 21695036508 21695036516 23490614401 23490614402 23490614403 23490614501 23490614502 23490614503 33358029108 38739015008 38779015003 38779015004 38779015005 38779015008 38779015009 49452598001 49452598002 49452598003 49999033508 49999033524 49999092901 50383004004 50383004224 50383004248 50383017708 51552002602 51552002604 51552002605 51927114800 52959062260 53014025001 54569133500 54569482700 54569482701 54569482702 54569520400 54569520401 54569574900 54868082100 54868095400 54868172000 54868322000 54868474800 54868474900 54868474901 54868524200 12/19/2013 HCPCS Description METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER METHYLPREDNISOLONE ORAL, PER PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG 4 4 4 4 MG MG MG MG Earliest Start Date 10/17/2005 10/17/2005 10/01/2003 03/26/2004 01/01/2002 01/01/2002 04/01/2003 04/17/2003 04/17/2003 05/02/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/05/2007 11/05/2007 01/01/2002 01/01/2002 01/01/2002 10/15/2007 10/15/2007 04/09/2007 10/11/2007 10/11/2007 10/11/2007 10/11/2007 10/11/2007 07/10/2007 09/24/2007 01/01/2002 01/01/2002 01/01/2002 04/25/2002 09/03/2002 01/01/2002 01/01/2002 01/01/2002 02/10/2004 05/10/2004 04/20/2007 01/22/2003 03/24/2003 03/17/2003 03/21/2005 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/04/2005 04/11/2007 12/16/2003 01/01/2002 01/01/2002 02/28/2003 02/28/2003 05/25/2004 03/03/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7510 J7511 J7513 J7515 J7515 J7515 J7515 J7515 J7515 J7515 J7515 J7515 J7515 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7516 J7517 J7517 J7517 J7517 55045288500 55045288508 55887037308 57866432701 58016067312 58016067324 58016067348 58016414401 58016484301 58177091005 58177091007 58177091203 58177093205 59196001024 59196001048 60432008904 60432021208 62991125701 62991125702 63629186201 65580025101 66440015008 66440015016 68115089808 68135045502 68135045503 68188048002 68188048202 68188048402 58468008001 00004050109 00074646332 00078024015 00078024061 00078024615 00172731046 00172731146 00185093230 00591222215 50111090943 60505013300 00078010901 00574086610 38779066003 38779066004 38779066005 38779066006 51552066301 51552066302 51552066304 51552066306 51927319600 55390012210 62991153301 62991153302 62991153305 63370005710 63370005715 63370005725 63370005735 63370005745 00004025901 00004025905 00004025943 00004026001 12/19/2013 HCPCS Description PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ORAL, PER 5 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, DACLIZUMAB, PARENTERAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG CYCLOSPORIN, PARENTERAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG Earliest Start Date 01/02/2006 07/05/2006 04/01/2004 04/15/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/01/2006 04/16/2002 04/16/2002 01/01/2002 05/25/2005 01/01/2002 01/01/2002 07/18/2002 10/25/2004 01/01/2002 09/15/2003 11/01/2004 05/09/2002 10/02/2003 10/02/2003 05/04/2004 02/01/2005 09/01/2005 04/03/2007 07/10/2006 01/04/2008 12/01/2005 01/01/2002 01/01/2002 01/01/2002 01/05/2012 01/01/2002 04/14/2005 04/14/2005 01/01/2002 12/23/2008 01/01/2002 05/17/2002 01/01/2002 11/19/2004 02/06/2002 02/06/2002 02/06/2002 02/06/2002 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 09/15/2003 09/15/2003 01/01/2008 07/08/2003 07/08/2003 07/08/2003 07/08/2003 12/19/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2009 01/31/2010 11/30/2010 12/31/2010 12/31/2078 12/31/2078 08/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/13/2013 12/31/2078 12/31/2078 12/31/2078 10/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7517 J7518 J7518 J7520 J7520 J7520 J7520 J7520 J7520 J7525 J7527 J7527 J7527 J7527 J7527 J7527 J7599 J7599 J7599 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7602 J7603 00004026043 00004026129 00054016325 00054016625 00093733405 00093733493 00093747701 00093747705 00378225001 00378447201 00378447205 00781206701 00781206705 00781206789 00781517501 00781517505 16729001901 16729009401 21695017100 49999093600 49999093630 49999093730 51079037920 67877022501 68382013005 68382013101 68382013105 00078038566 00078038666 00008103006 00008104005 00008104010 00008104105 00008104110 00008104205 00469301601 00078041420 00078041461 00078041520 00078041561 00078041720 00078041761 00469064773 00469067773 00469068773 00085133601 00182601465 00487990102 00487990130 00904765855 21695024520 23490502102 24208034720 50383074120 52959074120 54569390000 54868247201 54868340700 55045247002 55887038220 58016640401 63402051530 63874070820 68115071120 00085180601 12/19/2013 Earliest Start Date HCPCS Description MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG, MYCOPHENOLATE MOFETIL, ORAL, 250 MG, MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENALATE 250MG CAPSULE MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL , ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, 250 MG MYCOPHENOLIC ACID, ORAL, 180 MG MYCOPHENOLIC ACID, ORAL, 180 MG SIROLIMUS, ORAL, 1 MG SIROLIMUS, ORAL, 1 MG SIROLIMUS, ORAL, 1 MG SIROLIMUS, ORAL, 1 MG SIROLIMUS, ORAL, 1 MG SIROLIMUS, ORAL, 1 MG TACROLIMUS, PARENTERAL, 5 MG EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH INH INH INH INH INH INH INH INH INH INH INH INH INH INH INH INH INH INH INH 01/01/2002 01/01/2002 05/04/2009 05/04/2009 05/06/2009 05/06/2009 05/05/2009 05/05/2009 05/04/2009 05/04/2009 05/04/2009 05/04/2009 05/04/2009 05/04/2009 05/04/2009 05/04/2009 05/05/2009 05/05/2009 12/15/2006 12/21/2007 04/30/2007 04/30/2007 06/12/2009 03/20/2012 05/04/2009 05/04/2009 05/04/2009 01/01/2005 01/01/2005 01/01/2002 04/09/2010 04/09/2010 02/01/2006 05/26/2006 02/01/2006 01/01/2002 01/01/2013 01/01/2013 01/01/2013 01/01/2013 01/01/2013 01/01/2013 08/06/2013 08/06/2013 08/06/2013 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/24/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/29/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2008 Page 1 of 1 Earliest Start Date Latest End Date 38779049505 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 38779049508 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 38779049509 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 49452009701 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 49452009702 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 49452009703 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 49452009704 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 51552020104 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 51552020105 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 HCPCS NDC J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7603 J7604 00172640544 00172640549 00472083123 00472083130 00472083160 00487950101 00487950102 00487950103 00487950125 00487950160 00487990130 00487990401 00487990402 00487990425 00591346753 00591346853 12280024125 16252009722 16252009733 16252009766 21695033225 23490502001 23490502002 23490502003 49502069203 49502069303 49502069724 49502069729 49502069730 49502069761 49999034425 54569389900 54569474800 54569544500 54868247200 54868440900 54868545900 54868570900 55045204307 55887033224 63402051124 63402051224 63402051324 66794000125 66794000130 66794000160 38779049504 J7604 12/19/2013 HCPCS Description ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/01/2008 10/31/2009 10/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2012 01/31/2012 01/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2011 12/31/2078 07/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2009 06/30/2009 06/30/2009 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7604 51552020107 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM J7604 51927160100 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 62991100302 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 62991100303 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 62991100304 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 63370000525 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 63370000535 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 63370000545 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 63370000550 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 63370000555 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7604 63370000562 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2008 12/31/2078 J7605 J7605 J7606 63402091130 ARFOMOTEROL IHAL SOL, 15MCG 63402091164 ARFOMOTEROL IHAL SOL, 15MCG 49502060530 FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL 01/01/2007 01/01/2007 07/02/2012 12/31/2078 12/31/2078 12/31/2078 J7606 49502060561 FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL 10/02/2007 12/31/2078 J7608 00054302502 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 00054302602 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 00054302702 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 00054302802 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 00409330703 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 04/11/2005 12/31/2078 J7608 00409330803 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 05/25/2005 12/31/2078 J7608 00517750425 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/24/2003 12/31/2078 J7608 00517751003 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 00517760425 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/29/2003 12/31/2078 J7608 00517761003 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 00517763003 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 54868567000 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 08/10/2007 12/31/2078 J7608 54868567001 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 08/10/2007 12/31/2078 J7608 61703020331 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 61703020431 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 01/01/2002 12/31/2078 J7608 J7608 62991100301 ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PROD 62991100305 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME 10/31/2011 09/15/2003 12/31/2078 12/31/2078 J7608 J7609 63323069030 ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PROD 38779018504 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 09/19/2012 01/01/2007 12/31/2078 12/31/2078 J7609 38779018505 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 12/19/2013 01/01/2008 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7609 38779018508 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST J7609 38779018509 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 49452022501 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 49452022503 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 49452022701 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 49452022702 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 49452022703 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 51552004402 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 51552004404 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 51552004405 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 51552004406 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 51552004407 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 51927157300 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 51927285900 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 62991100601 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 62991100602 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 62991100603 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 62991100604 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 63275999904 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 63275999905 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 63370001025 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 63370001035 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 63370001045 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7609 63370001050 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIST 01/01/2007 12/31/2078 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 J7611 00182601465 00487990102 00487990130 00904765855 21695024520 23490502102 24208034720 50383074120 52959074120 54569390000 54868247201 54868340700 55045247002 55887038220 58016640401 59930164702 63874070820 68115071120 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 01/01/2005 04/01/2008 04/01/2008 12/31/2078 12/31/2078 12/31/2078 02/29/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2008 12/31/2078 12/31/2078 12/19/2013 ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, 01/01/2007 12/31/2078 Page 1 of 1 HCPCS NDC J7612 J7612 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 00378699393 63402051530 00378699052 00378699058 00378699091 00378699152 00378699252 00378827052 00472083123 00472083130 00472083160 00487030101 00487950101 00487950102 00487950103 00487950125 00487950160 00487990401 00487990402 00487990425 00591346753 00591346853 00591379730 00591379760 00591379783 12280024125 16252009722 16252009733 16252009766 21695033225 23490502001 23490502002 23490502003 38779018504 38779018505 38779018508 38779018509 49452022501 49452022503 49452022701 49452022702 49452022703 49502069203 49502069303 49502069724 49502069729 49502069730 49502069761 49999034425 50383074225 51552004402 51552004404 51552004405 51552004406 51552004407 51927157300 51927285900 54569389900 54868247200 54868570900 55045204307 59930151701 59930151702 62991100601 62991100602 12/19/2013 HCPCS Description LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, Earliest Start Date 08/28/2009 04/01/2008 10/07/2009 10/07/2009 10/07/2009 11/02/2009 11/02/2009 12/13/2012 04/01/2008 04/01/2008 04/01/2008 07/19/2010 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 11/04/2010 11/04/2010 11/04/2010 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 04/01/2008 04/01/2008 04/01/2008 04/01/2008 01/01/2005 01/01/2005 01/01/2005 01/01/2005 Latest End Date 12/31/2078 12/31/2078 04/30/2014 04/30/2014 01/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2012 01/31/2012 01/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2011 12/31/2078 07/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2008 06/30/2008 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 62991254902 LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMIN 01/01/2007 12/31/2078 00093672373 00093672374 00185732213 00185732230 00185732260 00378698858 00378698891 00378698893 00378967158 00487020101 00487020102 00487020106 00487020160 00591343330 00591343360 00591381730 00591381760 00781714664 16252054733 16252054766 49502067230 49502067231 49502067260 76204060005 76204060012 01/03/2008 01/03/2008 07/01/2007 07/01/2007 07/01/2007 12/28/2007 12/28/2007 12/28/2007 09/26/2013 01/01/2008 01/01/2008 01/01/2008 01/01/2008 01/02/2008 01/02/2008 05/13/2013 05/13/2013 07/30/2013 12/31/2007 12/31/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2013 01/01/2013 12/31/2078 12/31/2078 12/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2015 02/28/2015 12/31/2078 05/31/2009 12/31/2078 12/31/2078 12/31/2078 HCPCS NDC J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7613 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7614 J7615 62991100603 62991100604 63275999904 63275999905 63370001025 63370001035 63370001045 63370001050 66794000125 66794000130 66794000160 76204020025 76204020030 76204020060 00378968044 00378968144 00378968244 00591291823 00591291923 00591292023 54569474800 54569544500 54868440900 54868545900 55887033224 62991254901 62991254902 63402051124 63402051224 63402051324 66993002127 66993002227 66993002327 76204000224 76204000324 62991254901 J7615 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 J7620 12/19/2013 HCPCS Description ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUC LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMIN ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, ALBUTEROL, UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND AND IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP UP TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO TO 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 M M M M M M M M M M M M M M M M M M M M M M M M M 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 04/01/2008 04/01/2008 04/01/2008 02/01/2012 02/01/2012 02/01/2012 03/15/2013 03/15/2013 03/15/2013 08/20/2012 08/20/2012 08/20/2012 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 01/01/2006 01/01/2006 04/01/2008 04/01/2008 04/01/2008 08/23/2012 08/23/2012 08/23/2012 02/01/2013 02/18/2013 01/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2009 06/30/2009 06/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7622 38779036401 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD J7622 38779036403 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 02/07/2002 12/31/2078 J7622 38779036406 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 02/07/2002 12/31/2078 J7622 49452080201 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2002 12/31/2078 J7622 49452080202 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2002 12/31/2078 J7622 49452080203 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2002 12/31/2078 J7622 51552088301 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 09/01/2003 12/31/2078 J7622 51552088302 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 09/01/2003 12/31/2078 J7622 51552088309 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 09/01/2003 12/31/2078 J7622 51927164100 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 09/08/2003 12/31/2078 J7622 62991102001 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2002 12/31/2078 J7622 62991102002 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2002 12/31/2078 J7622 62991102003 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 09/15/2003 12/31/2078 J7624 38779001701 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 38779001703 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 38779001704 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 38779001706 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 38779019501 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 38779019503 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 38779019506 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107004 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107005 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107006 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107501 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107502 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107503 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2004 12/31/2078 J7624 49452107701 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107702 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 49452107704 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2004 12/31/2078 J7624 51552006401 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 51552006402 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7624 51927145400 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/08/2003 12/31/2078 J7624 51927195100 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/08/2003 12/31/2078 12/19/2013 02/07/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7624 62991102301 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI J7624 62991102302 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 62991102303 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 62991102401 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 62991102402 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7624 62991102404 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/15/2003 12/31/2078 J7624 62991102405 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/15/2003 12/31/2078 J7624 63370002806 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7624 63370002810 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7624 63370002815 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7624 63370002825 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7624 63370002835 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7626 J7626 J7626 J7626 J7626 J7626 J7626 J7626 J7627 00093681573 00093681673 00186198804 00186198904 00186199004 38779019804 54868562100 54868577400 38779019800 FDA-APPROVED FINAL PRODUCT, FDA-APPROVED FINAL PRODUCT, FDA-APPROVED FINAL PRODUCT, FDA-APPROVED FINAL PRODUCT, FDA-APPROVED FINAL PRODUCT, FDA-APPROVED FINAL PRODUCT, FDA-APPROVED FINAL PRODUCT, FDA-APPROVED FINAL PRODUCT, COMPOUNDED PRODUCT, ADMINIS 12/15/2009 12/15/2009 01/01/2002 01/01/2002 08/27/2007 04/19/2002 07/17/2007 06/01/2007 01/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 J7627 38779019803 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 38779019805 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 38779019806 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 49452129101 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 49452129102 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 49452129103 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 51552066801 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 51927283400 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 62991117901 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 62991117902 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 62991117903 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 62991117905 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 63370003509 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 63370003510 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 63370003515 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7627 63370003525 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 12/19/2013 BUDESONIDE, BUDESONIDE, BUDESONIDE, BUDESONIDE, BUDESONIDE, BUDESONIDE, BUDESONIDE, BUDESONIDE, BUDESONIDE, INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7631 00172640649 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DM J7631 00172640659 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DM 01/01/2002 12/31/2078 J7631 49502068961 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DM 03/01/2004 11/30/2009 J7631 54868355500 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DM 03/24/2003 12/31/2078 J7631 60505080201 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DM 05/31/2002 12/31/2078 J7631 60793001012 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DM 12/15/2005 02/28/2009 J7631 60793001060 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DM 12/15/2005 02/28/2009 J7632 38779030103 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 38779030104 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 38779030105 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 38779030108 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 38779030109 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 49452000601 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 49452000602 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 49452000603 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 49452000604 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 51552042302 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 51552042304 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 51552042305 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 51552042307 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 62991103801 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 62991103802 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 62991103803 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 62991103804 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 63370005015 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 63370005025 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 63370005035 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 63370005045 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7632 63370005050 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, AD 01/01/2008 12/31/2078 J7636 17317003602 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 17317003605 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 17317003607 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 38779001401 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7636 38779001404 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE J7636 38779001405 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 49452077001 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 49452077002 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 49452077003 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 49452078001 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 49452078002 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 49452078003 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 01/01/2002 12/31/2078 J7636 51552015602 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 09/01/2003 12/31/2078 J7636 51552015604 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 09/01/2003 12/31/2078 J7636 51552099902 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 09/01/2003 12/31/2078 J7636 51552099904 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 09/01/2003 12/31/2078 J7636 51927100100 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTE 09/08/2003 12/31/2078 J7638 00574040810 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 02/28/2010 J7638 38779007101 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 38779007103 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 38779007104 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 38779007105 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/03/2002 12/31/2078 J7638 38779007108 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/03/2002 12/31/2078 J7638 38779040501 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 38779040503 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 38779040504 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 38779040505 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 38779040506 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452246501 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452246502 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452246503 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452246504 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452247001 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452247002 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452247003 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 49452247004 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 51552002501 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7638 51552002502 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI J7638 51552002503 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7638 51552002504 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7638 51552043001 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 51552043002 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7638 51927143000 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/08/2003 12/31/2078 J7638 62991104101 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 10/31/2011 12/31/2078 J7638 62991104102 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 62991104103 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 62991104104 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 62991202202 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 62991202203 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 62991202204 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7638 63370007010 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7638 63370007015 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7638 63370007020 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7638 63370007025 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7638 63370007035 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7638 63370007045 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7638 63370007050 DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 07/08/2003 12/31/2078 J7639 50242010039 DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, 01/01/2002 12/31/2078 J7639 50242010040 DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, 01/01/2002 12/31/2078 J7640 51927364300 FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7640 62991251601 FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7640 62991251602 FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7640 62991251603 FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2006 12/31/2078 J7640 63370006909 FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 10/24/2006 12/31/2078 J7640 63370006910 FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 10/24/2006 12/31/2078 J7641 J7641 J7641 J7641 J7641 J7641 J7641 J7641 J7641 J7641 38779040600 38779040606 38779040609 49452316201 49452316202 49452316203 51552061101 51552061102 51927179400 62991159001 01/01/2002 01/01/2002 04/26/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/08/2003 09/15/2003 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, FLUNISOLIDE, INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, COMPOUNDED COMPOUNDED COMPOUNDED COMPOUNDED COMPOUNDED COMPOUNDED COMPOUNDED COMPOUNDED COMPOUNDED COMPOUNDED PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, PRODUCT, ADMINI ADMINI ADMINI ADMINI ADMINI ADMINI ADMINI ADMINI ADMINI ADMINI 09/01/2003 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7641 J7641 J7643 62991159002 FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINI 62991159003 FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINI 00517460125 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM J7643 00517460225 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 12/31/2078 J7643 00517460525 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 12/31/2078 J7643 00517462025 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 12/31/2078 J7643 10019001602 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 09/28/2005 04/30/2014 J7643 10019001617 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 03/31/2014 J7643 10019001629 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 05/05/2007 04/30/2014 J7643 10019001654 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 01/31/2014 J7643 10019001663 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 11/30/2007 J7643 10019001681 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 03/31/2014 J7643 38779208703 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 05/02/2002 12/31/2078 J7643 38779208706 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 05/02/2002 12/31/2078 J7643 49452335801 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2003 12/31/2078 J7643 49452335802 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2003 12/31/2078 J7643 51552004201 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 12/31/2078 J7643 51927157500 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 09/08/2003 12/31/2078 J7643 54868323101 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 01/01/2002 12/31/2078 J7643 60977015501 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 02/13/2004 03/31/2014 J7643 60977015502 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 02/13/2004 03/31/2014 J7643 60977015503 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 02/13/2004 01/31/2014 J7643 60977015506 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 03/02/2006 10/31/2013 J7643 60977015517 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 05/05/2007 12/31/2078 J7643 60977015554 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 05/05/2007 01/31/2014 J7643 60977015563 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 05/05/2007 12/31/2078 J7643 60977015581 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADM 05/05/2007 03/31/2014 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 00172640744 00172640749 00378698962 00378698964 00378698966 00378698993 00378797052 00472075323 00472075330 00472075360 00487980101 00487980102 00487980125 00487980130 01/01/2002 01/01/2002 10/07/2009 10/07/2009 10/07/2009 10/07/2009 04/03/2013 01/23/2004 09/11/2003 09/09/2003 01/03/2003 07/20/2005 10/11/2002 01/03/2003 04/30/2010 03/31/2010 12/31/2013 12/31/2013 09/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FDA-APPROVED FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL FINAL 09/15/2003 09/15/2003 01/01/2002 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 38779023004 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 38779023005 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 38779023006 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 49452379102 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 49452379103 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 51552039301 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 51552039302 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 HCPCS NDC J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7644 J7645 00487980160 00591379830 00591379860 12280009430 16252009822 16252009833 16252009866 23490576101 35356012430 38779023003 38779023004 38779023005 38779023006 49452379102 49452379103 49502068526 49502068530 49502068531 49502068562 51552039301 51552039302 51552039304 51552039305 51927164800 54569491000 54868408200 54868408201 58016484901 60505080601 62991108501 62991108502 62991108503 62991108504 62991108505 62991108506 63275999801 63275999802 63275999804 63275999805 63370012010 63370012015 63370012025 63370012035 63370012050 66794000225 66794000230 66794000260 76204010025 76204010030 76204010060 38779023003 J7645 12/19/2013 HCPCS Description IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM IPRATROPIUM BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, BROMIDE, INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, SOLUTION, FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL FDA-APPROVED FINAL COMPOUNDED PRODUCT 01/03/2003 06/24/2011 05/23/2011 03/30/2005 04/01/2006 04/01/2006 04/01/2006 04/09/2007 03/13/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/20/2006 01/01/2005 06/01/2005 06/01/2005 01/01/2002 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 02/01/2006 01/01/2002 01/01/2002 01/01/2002 09/15/2003 09/15/2003 09/15/2003 09/15/2003 12/04/2002 12/04/2002 12/04/2002 12/04/2002 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 04/15/2002 04/15/2002 04/15/2002 02/01/2012 02/01/2012 02/01/2012 01/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2012 11/30/2012 03/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2009 05/31/2009 06/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7645 51552039304 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT J7645 51552039305 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 51927164800 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 62991108501 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 62991108502 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 62991108503 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 62991108504 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 62991108505 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 62991108506 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63275999801 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63275999802 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63275999804 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63275999805 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63370012010 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63370012015 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63370012025 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63370012035 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7645 63370012050 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2007 12/31/2078 J7659 J7659 J7659 J7659 J7660 J7660 J7660 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 J7669 00074141001 00409141001 00409141005 51927194000 00409141001 00409141005 51927194000 38779017101 38779017104 38779017105 38779017108 38779017109 49452455502 49452455503 49452455505 49502067624 49502067824 51552007902 51552007904 51552007905 51552007907 51927137000 52959015806 60505080701 60505080801 62991109902 62991109903 63370015320 63370015325 63370015335 02/22/2002 07/28/2005 10/26/2005 09/08/2003 01/01/2007 01/01/2007 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/01/2004 02/01/2004 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2009 05/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL P ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL P ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL P ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL P ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI 01/01/2007 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7669 J7670 63370015345 METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FI 49452455502 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD J7670 49452455503 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 49452455505 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 51552007902 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 51552007904 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 51552007905 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 51552007907 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 51927137000 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 62991109902 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 62991109903 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 63370015320 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 63370015325 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 63370015335 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7670 63370015345 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PROD 01/01/2007 12/31/2078 J7674 64281010006 METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION TH 01/01/2005 12/31/2078 J7674 64281010012 METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION TH 01/01/2005 12/31/2078 J7676 00074454801 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRO 01/01/2008 12/31/2078 J7676 63323011310 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRO 01/01/2008 12/31/2078 J7681 38779038101 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2002 12/31/2078 J7681 38779038103 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 09/03/2002 12/31/2078 J7681 38779038104 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2002 12/31/2078 J7681 38779038105 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2002 12/31/2078 J7681 49452763101 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 05/09/2002 12/31/2078 J7681 49452763102 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 05/09/2002 12/31/2078 J7681 49452763105 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 05/09/2002 12/31/2078 J7681 51552044603 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 09/01/2003 12/31/2078 J7681 51552044604 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 09/01/2003 12/31/2078 J7681 51927276500 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 09/08/2003 12/31/2078 J7681 62991115201 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2002 12/31/2078 J7681 62991115202 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 01/01/2002 12/31/2078 J7681 63370025015 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 07/08/2003 12/31/2078 J7681 63370025020 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 07/08/2003 12/31/2078 12/19/2013 07/08/2003 01/01/2007 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7681 63370025025 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT J7681 63370025035 TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT 07/08/2003 12/31/2078 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7682 J7684 00078049471 10122082056 38779031901 38779031903 38779031904 38779031905 38779031906 39822041201 39822041206 49452782301 49452782302 51552078901 51552078902 51552078904 51552078905 51927237500 53905006501 53905006504 62991135101 62991135102 62991135103 62991135104 62991135105 63323030351 63323030355 63370027510 63370027515 63370027525 63370027535 00574045005 TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 04/01/2008 09/20/2013 01/01/2002 01/01/2002 05/13/2002 05/13/2002 01/01/2002 01/01/2002 01/01/2002 11/15/2004 11/15/2004 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 01/01/2002 06/17/2005 01/01/2002 01/01/2002 01/01/2002 09/15/2003 09/15/2003 06/21/2004 12/17/2004 07/08/2003 07/08/2003 07/08/2003 07/08/2003 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 J7684 17317071901 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 17317071907 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 38779001101 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 38779001103 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 38779001104 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 38779001105 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 38779005101 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 38779005103 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 38779005104 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 04/30/2002 12/31/2078 J7684 38779005105 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 04/30/2002 12/31/2078 J7684 39822530005 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 02/28/2013 J7684 49452789002 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 49452789003 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 49452790001 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 49452790002 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 12/19/2013 07/08/2003 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7684 49452790003 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI J7684 49452790004 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 51552003301 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 51552003302 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7684 51552003303 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7684 51552003305 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7684 51552076801 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/01/2003 12/31/2078 J7684 51927132600 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/08/2003 12/31/2078 J7684 51927257500 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 09/08/2003 12/31/2078 J7684 62991115601 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 62991115602 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7684 62991115603 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMI 01/01/2002 12/31/2078 J7685 38779031901 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 38779031903 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 38779031904 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 38779031905 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 38779031906 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 39822041201 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 39822041206 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 49452782301 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 49452782302 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 51552078901 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 51552078902 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 51552078904 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 51552078905 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 51927237500 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 62991135101 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 62991135102 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 62991135103 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 62991135104 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 62991135105 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 63323030351 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 63323030355 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7685 63370027510 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS J7685 63370027515 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 63370027525 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7685 63370027535 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINIS 01/01/2007 12/31/2078 J7686 J7686 J7686 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 66302020601 66302020602 66302020603 00074454801 38779030103 38779030104 38779030105 38779030108 38779030109 38779049504 38779049505 38779049508 38779049509 38779063204 38779063205 38779063208 38779063209 49452000601 49452000602 49452000603 49452000604 49452009701 49452009702 49452009703 49452009704 49452326101 49452326102 49452326103 49502064115 51552020104 51552020105 51552020107 51552042302 51552042304 51552042305 51552042307 51552077501 51552077502 51552077504 51552077505 51927160100 51927161000 62991100302 62991100303 62991100304 62991100305 62991103801 62991103802 62991103803 62991103804 62991107201 62991107202 62991107203 63323011310 63370000525 63370000535 63370000545 63370000550 08/14/2009 08/14/2009 08/14/2009 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 09/01/2003 09/01/2003 09/01/2003 09/01/2003 01/01/2007 09/08/2003 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 09/01/2002 09/01/2002 09/01/2002 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION INHALATION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED ADMINISTERED THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH THROUGH DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME DME 01/01/2007 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 00053759610 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/01/2006 05/06/2013 J7799 00053759615 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/01/2006 12/31/2078 J7799 00053759620 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/01/2006 06/08/2013 J7799 00053759625 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/01/2006 12/31/2078 J7799 00074177510 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 06/01/2007 J7799 00074490234 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 10/01/2007 J7799 00074564125 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00074564425 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00074751716 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 09/01/2007 J7799 00264112701 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264112950 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 09/30/2010 J7799 00264120755 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 06/30/2010 J7799 00264121710 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264122200 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264124055 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264125055 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 07/31/2010 J7799 00264125155 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264126055 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 07/31/2010 J7799 00264127050 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264128050 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264128055 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 09/30/2014 J7799 00264128155 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264129050 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 05/31/2013 J7799 00264129055 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 HCPCS NDC J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7699 J7799 63370000555 63370000562 63370005015 63370005025 63370005035 63370005045 63370005050 63370009815 63370009825 63370009835 63370009850 63370009855 63402091130 63402091164 68115065160 00053759603 J7799 12/19/2013 HCPCS Description NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC NOC DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME INHALATION SOLUTION ADMINISTERED THROUGH DME OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 07/08/2003 07/08/2003 07/08/2003 07/08/2003 07/08/2003 04/04/2007 01/31/2007 04/19/2004 03/01/2006 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7799 00264222055 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH J7799 00264230350 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264402155 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 09/30/2015 J7799 00264752000 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264752010 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264757810 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264757820 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264760500 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264760510 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 02/28/2014 J7799 00264760800 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264760810 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264760820 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264760830 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761200 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761210 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761220 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761400 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761410 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761600 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761610 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264761620 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264762200 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264762320 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264780200 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264780210 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264780510 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00264780610 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338001204 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 10/31/2009 J7799 00338002302 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338002303 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338002304 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338002313 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 04/30/2008 J7799 00338002334 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7799 00338003003 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH J7799 00338003106 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338003113 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 01/31/2008 J7799 00338003134 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 01/31/2008 J7799 00338003603 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 10/31/2009 J7799 00338003804 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 10/31/2009 J7799 00338004303 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338004304 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338005403 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338005603 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338007303 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 07/31/2011 J7799 00338007304 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338007702 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338007703 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338007704 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338008102 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 05/31/2007 J7799 00338008103 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338008104 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 04/30/2007 J7799 00338008502 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338008503 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338008504 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338035104 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338035303 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338035304 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338035503 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338035702 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338035703 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338064002 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 06/30/2009 J7799 00338071113 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 04/30/2008 J7799 00338071134 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 01/31/2008 J7799 00338071313 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2007 J7799 00338071334 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338071513 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 08/31/2007 12/19/2013 01/01/2002 09/30/2009 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7799 00338071534 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH J7799 00338071906 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338071913 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00338087302 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 06/30/2010 J7799 00409113002 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 05/13/2005 12/31/2078 J7799 00409114102 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/13/2005 12/31/2078 J7799 00409150805 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/31/2005 07/01/2011 J7799 00409153405 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 02/24/2006 07/01/2011 J7799 00409153503 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/08/2005 10/01/2011 J7799 00409158603 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/24/2006 12/31/2078 J7799 00409177510 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 02/20/2006 12/31/2078 J7799 00409408902 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 05/18/2005 11/01/2012 J7799 00409421902 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/30/2005 12/31/2078 J7799 00409486202 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/09/2005 12/31/2078 J7799 00409486203 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/04/2005 10/01/2011 J7799 00409490234 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/08/2005 12/31/2078 J7799 00409664802 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/29/2005 12/31/2078 J7799 00409665773 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 10/14/2005 12/31/2078 J7799 00409666075 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 07/26/2005 12/31/2078 J7799 00409711907 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 05/27/2006 10/01/2011 J7799 00409712007 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 07/06/2005 12/31/2078 J7799 00409713202 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 05/26/2006 12/31/2078 J7799 00409713266 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/12/2005 12/31/2078 J7799 00409713267 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 11/14/2005 12/31/2078 J7799 00409751716 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/07/2005 12/31/2078 J7799 00409771209 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/19/2005 12/31/2078 J7799 00409771309 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/07/2006 12/31/2078 J7799 00409771403 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/30/2005 12/31/2078 J7799 00409771502 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 11/14/2005 12/31/2078 J7799 00409771503 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/16/2005 12/31/2078 J7799 00409773020 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 07/27/2005 12/31/2078 J7799 00409773036 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 07/11/2005 12/31/2078 J7799 00409773037 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/16/2005 12/31/2078 12/19/2013 01/01/2002 09/30/2007 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7799 00409791819 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH J7799 00409792402 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 07/28/2005 12/31/2078 J7799 00409792403 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 07/28/2005 12/31/2078 J7799 00409792409 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/21/2005 12/31/2078 J7799 00409792502 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 06/29/2005 04/01/2012 J7799 00409792503 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/16/2005 12/31/2078 J7799 00409792509 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/17/2006 12/31/2078 J7799 00409792602 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/30/2005 12/31/2078 J7799 00409792603 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 06/07/2005 12/31/2078 J7799 00409792609 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/25/2005 12/31/2078 J7799 00409792630 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/14/2006 12/31/2078 J7799 00409792648 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/14/2006 12/31/2078 J7799 00409793002 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 07/05/2005 12/31/2078 J7799 00409793003 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/12/2005 12/31/2078 J7799 00409793009 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 03/16/2005 12/31/2078 J7799 00409793519 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/12/2005 12/31/2078 J7799 00409793619 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 06/24/2005 12/31/2078 J7799 00409793629 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 10/28/2005 12/31/2078 J7799 00409793719 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/24/2005 12/31/2078 J7799 00409793819 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/29/2005 12/31/2078 J7799 00409798502 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/06/2005 12/31/2078 J7799 00409798503 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/06/2005 12/31/2078 J7799 00409798509 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 11/24/2004 12/31/2078 J7799 00409800415 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/01/2005 12/31/2078 J7799 00469325010 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 05/03/2005 12/31/2078 J7799 00517290025 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 01/31/2013 J7799 00517293025 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 00548100100 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 05/31/2012 J7799 00548101500 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 05/31/2009 J7799 00548200100 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 08/31/2012 J7799 00548330100 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 09/30/2014 J7799 00548331500 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 06/30/2012 J7799 15927322000 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/08/2003 12/31/2078 12/19/2013 07/08/2005 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date J7799 17317041702 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH J7799 17317041703 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 17317041705 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 38779024704 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 38779024705 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 38779043604 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/21/2002 12/31/2078 J7799 38779043605 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 08/21/2002 12/31/2078 J7799 38779206503 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 05/02/2002 12/31/2078 J7799 38779206506 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 05/02/2002 12/31/2078 J7799 44206045101 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/01/2010 12/31/2078 J7799 44206045202 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/01/2010 12/31/2078 J7799 44206045404 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 04/01/2010 12/31/2078 J7799 49452274001 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 49452529001 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 49452529002 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 49452529003 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 51552023202 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/01/2003 12/31/2078 J7799 51552023204 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/01/2003 12/31/2078 J7799 51552023205 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/01/2003 12/31/2078 J7799 51552052605 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/01/2003 12/31/2078 J7799 51927122500 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/08/2003 12/31/2078 J7799 51927171500 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 09/08/2003 12/31/2078 J7799 54868308900 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/11/2006 12/31/2078 J7799 54868308901 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/05/2007 12/31/2078 J7799 54868370300 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 54868572700 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/12/2006 12/31/2078 J7799 63323008861 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 63323008863 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 63323013920 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 63323013940 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 63323018730 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 01/01/2002 12/31/2078 J7799 63370008807 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/19/2003 12/31/2078 J7799 63370008815 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH 12/19/2003 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description J7799 63370008825 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 00182709611 00182709911 00182710011 00182710111 00574722612 00574723412 00574723612 00713013512 00713052612 00713053612 16590019312 16590019412 21695064912 23490617401 23490618001 23490618201 23490618202 23490618203 33358030102 33358030112 35356003912 45802075830 45802075930 49999033912 49999034012 52959023712 52959029100 52959035506 52959035512 52959056101 52959056104 52959056201 52959056206 54569035301 54569035302 54569472000 54569472002 54569574400 54569574401 54569574500 54569574501 54569574502 54868060101 54868060102 54868062200 54868062202 54868161302 54868193200 54868193201 54868193202 54868311200 54868311201 54868468600 54868468601 54868479402 55045174902 55045240002 55045301102 55045301103 55289011902 55289011906 55289041404 55289041406 12/19/2013 ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC ANTIEMETIC DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, RECTAL/SUPPOSITORY, NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT NOT OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE OTHERWISE SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED SPECIFIED Earliest Start Date Latest End Date 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 02/01/2006 02/01/2006 11/12/2007 02/07/2007 02/07/2007 02/07/2007 02/07/2007 11/30/2007 07/10/2007 07/10/2007 10/19/2007 01/01/2006 01/01/2006 09/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 09/11/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 04/26/2006 08/08/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 02/28/2010 03/31/2009 03/31/2011 12/31/2009 12/31/2078 07/31/2014 07/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2003 12/31/2078 Page 1 of 1 HCPCS NDC J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8498 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 55289092802 55289092804 55289092806 55289092879 55289094002 55289094006 55887022012 55887062103 55887062112 58016301803 58016306601 58016306701 58016322201 58016500901 58016650601 63874080612 66336015003 66336015006 68115029912 68115069112 00093894001 00093894005 00093894093 00093894301 00093894305 00093894701 00093894705 00172426760 00172426770 00172426860 00172426870 00173094555 00173094955 00173095396 00173099155 00173099156 00182266689 00182266789 00182820089 00228260511 00228260550 00228260611 00228260650 00228260711 00228260750 00378025301 00378030201 00472008216 00591033501 00591033601 00591269201 00904578961 00904579061 00904579961 13411018201 13411018203 13411018206 13411018209 13411018210 13411018301 13411018303 13411018306 13411018309 13411018310 16477051008 12/19/2013 HCPCS Description ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS Earliest Start Date 03/01/2006 05/09/2006 01/01/2006 01/01/2006 03/01/2006 05/09/2006 04/01/2007 01/01/2006 04/01/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/15/2006 01/01/2006 04/20/2007 04/13/2006 01/01/2006 01/01/2002 01/01/2002 11/30/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 10/22/2003 07/02/2003 01/01/2003 01/03/2007 01/08/2007 01/12/2007 08/23/2006 08/23/2006 08/23/2006 08/23/2006 08/23/2006 08/23/2006 08/23/2006 08/23/2006 08/23/2006 08/23/2006 04/30/2008 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/03/2008 12/31/2078 12/31/2078 12/31/2078 03/31/2007 12/31/2078 03/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2012 10/31/2012 05/31/2012 12/31/2078 12/31/2078 07/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 16590000330 16590000360 16590037020 16590037030 16590037040 21695001020 21695001025 21695001030 21695001060 21695001130 23490501101 23490501201 23490501202 23490501203 23490501204 23490501301 23490501302 23490501303 23490501304 23490501501 23490501502 33358000925 33358001015 33358001028 33358001030 33358001060 33358001125 33358001130 33358001135 49884056501 49884056601 49884056701 49999008600 49999008625 49999008630 49999008690 49999023135 49999038510 49999038515 49999038525 49999038540 50383081016 51079087601 51079087620 51079087701 51079087720 51079087801 51079087820 51655029651 51655029654 51655029676 51655030051 51655030054 51655030076 52959033000 52959033025 52959033050 52959051725 52959051730 52959051735 52959054401 52959054410 52959054412 52959054415 52959054421 12/19/2013 HCPCS Description PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS Earliest Start Date 02/01/2006 02/01/2006 06/01/2006 06/01/2006 06/01/2006 11/30/2006 05/19/2008 02/01/2007 11/30/2006 05/19/2008 10/11/2007 02/07/2007 02/07/2007 02/07/2007 02/07/2007 02/07/2007 02/07/2007 02/07/2007 10/11/2007 02/07/2007 10/11/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 01/01/2002 01/01/2002 01/01/2002 09/01/2006 07/29/2002 07/13/2005 07/13/2005 06/02/2005 06/09/2004 06/09/2004 06/09/2004 06/02/2005 06/13/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/22/2005 06/22/2005 06/22/2005 06/22/2005 06/22/2005 06/22/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2011 12/31/2011 02/29/2012 02/29/2012 12/31/2011 12/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 52959054425 52959054430 52959054440 52959054450 52959067830 54569448200 54569448201 54569448204 54569448206 54569472400 54569476501 54569476502 54569476503 54569476504 54569476505 54569476506 54569476509 54868016302 54868218400 54868218402 54868218403 54868218404 54868302500 54868399600 54868399601 54868399602 54868399603 54868399604 54868399605 54868399700 54868399701 54868399702 54868399703 54868399704 54868399705 54868399800 54868399801 54868399802 54868399803 54868399804 54868399805 54868399806 54868399807 54868399808 55045256500 55045256502 55045256504 55045256505 55045256508 55045257100 55045257102 55045257104 55045257105 55045257106 55045257108 55045264800 55045264802 55045264803 55045264805 55045264806 55289000610 55289000625 55289000635 55289000650 55289027310 12/19/2013 HCPCS Description PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS Earliest Start Date 01/01/2002 01/01/2002 08/24/2007 01/01/2002 10/07/2003 01/01/2002 01/01/2002 09/11/2002 04/26/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/17/2004 08/06/2007 01/01/2002 06/12/2003 09/25/2003 10/20/2003 11/03/2003 08/01/2005 01/01/2002 01/01/2002 03/05/2003 12/08/2003 01/28/2004 06/09/2004 07/06/2004 07/23/2004 04/22/2005 01/01/2005 12/06/2004 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2005 01/01/2003 01/01/2005 03/01/2005 01/01/2005 01/01/2005 07/01/2003 01/01/2005 01/01/2005 01/01/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 55289027325 55289027330 55289027335 55289027350 55289046205 55289046212 55289046215 55289046221 55289046225 55289046230 55289046235 55289046260 55289056415 55289056420 55289056448 55289062910 55289062930 55289062950 55289069112 55289069115 55289069125 55887024615 55887024621 55887024625 55887024630 55887024640 55887024650 55887024660 55887085325 55887085330 55887085335 55887085350 55887085360 55887085390 55887097730 55887097740 57866695002 57866695003 58016011100 58016011115 58016011120 58016011125 58016011130 58016011160 58016011190 58016011200 58016011220 58016011230 58016011260 58016011290 58016062700 58016062720 58016062730 58016062760 58016062790 58864019125 58864019135 58864060201 58864060230 58864087635 60429071150 60429071350 60505004206 60505530601 60505530608 12/19/2013 HCPCS Description PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS Earliest Start Date 01/01/2002 08/01/2006 01/01/2002 01/01/2002 01/15/2004 01/01/2002 01/01/2002 08/17/2006 01/01/2002 01/01/2002 04/21/2008 03/01/2006 01/01/2002 01/01/2002 01/01/2002 08/26/2002 06/05/2007 04/23/2008 01/01/2002 01/01/2002 01/01/2002 04/01/2007 02/01/2005 02/01/2005 02/01/2005 04/01/2007 02/01/2005 03/23/2007 04/01/2004 04/01/2004 04/01/2007 04/01/2007 04/01/2004 04/01/2004 04/01/2007 11/29/2005 04/15/2002 04/15/2002 09/01/2006 09/01/2006 09/01/2006 09/01/2006 09/01/2006 09/01/2006 09/01/2006 05/31/2005 05/31/2005 05/31/2005 08/09/2002 05/31/2005 01/29/2002 01/29/2002 01/29/2002 01/29/2002 01/29/2002 03/01/2004 03/01/2004 06/01/2004 03/02/2004 01/01/2005 01/01/2002 01/01/2002 03/01/2006 03/01/2006 05/21/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 60505530701 60505530705 62033020410 62033020414 63304050401 63304050501 63304065201 63304065205 63629167601 63629167602 63629167603 63629167701 63629167702 63629167703 63629167801 63629167802 63629167803 63739031410 63739031415 63739031510 63739031515 63739031610 63739031615 63874040401 63874040410 63874040414 63874040415 63874040420 63874040424 63874040425 63874040430 63874040435 63874040440 63874040450 63874040460 63874040501 63874040510 63874040520 63874040525 63874040530 63874040535 63874050001 63874050015 63874050020 63874050021 63874050025 63874050030 63874050040 63874050060 66267000625 66267000640 66267000650 66267000715 66267000721 66267000725 66267000730 66267039930 66336064225 66336064230 66336064240 66336064250 66336073515 66336073525 66336073540 66336086250 12/19/2013 HCPCS Description PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON NON CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS Earliest Start Date 03/01/2006 05/21/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 02/27/2007 06/09/2004 02/27/2007 06/09/2004 02/27/2007 06/09/2004 01/23/2002 01/23/2002 01/23/2002 01/23/2002 01/23/2002 01/23/2002 01/23/2002 01/23/2002 01/15/2006 01/23/2002 01/23/2002 01/23/2002 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 03/15/2006 01/23/2002 03/15/2006 03/15/2006 03/15/2006 03/15/2006 03/15/2006 03/15/2006 04/08/2002 08/01/2002 04/08/2002 04/08/2002 04/08/2002 04/08/2002 04/08/2002 03/15/2005 10/22/2004 06/22/2005 10/22/2004 01/07/2008 10/22/2004 10/22/2004 10/22/2004 05/01/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/01/2010 12/31/2078 05/01/2010 12/31/2078 08/01/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8499 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8501 J8510 J8515 J8515 J8515 J8515 J8515 J8520 J8520 J8520 J8520 J8520 J8521 J8521 J8521 J8521 J8521 J8521 J8521 J8521 J8521 J8521 J8521 J8521 J8530 J8530 J8530 J8530 J8530 J8530 J8530 J8530 67253010010 67253010011 67253010110 67253010111 67253010210 67253010250 68115000510 68115000525 68115000530 68115000540 68115000610 68115000615 68115000621 68115000625 68115000630 68115000660 68115000730 68115000740 00006046102 00006046105 00006046106 00006046130 00006046205 00006046206 00006046230 00006046405 00006046410 00006386203 52959074801 54569574100 54868523100 54868523101 54868523102 54868532500 00173071325 00093542088 16252053608 49884067314 59762010001 68084024521 00004110020 54868414300 54868414301 54868414302 54868414303 00004110150 54569571700 54868526000 54868526001 54868526002 54868526003 54868526004 54868526005 54868526006 54868526007 54868526008 54868526009 00015050301 00015050401 00054412925 00054413025 00054808925 00054813025 54868500500 54868500501 12/19/2013 HCPCS Description PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG APREPITANT, ORAL, 5 MG BUSULFAN, 2 MG, ORAL CABERGOLINE, ORAL, 0.25 MG CABERGOLINE, ORAL, 0.25 MG CABERGOLINE, ORAL, 0.25 MG CABERGOLINE, ORAL, 0.25 MG CABERGOLINE, ORAL, 0.25 MG CAPECITABINE, 150 MG, ORAL CAPECITABINE, ORAL, 150 MG CAPECITABINE, ORAL, 150 MG CAPECITABINE, ORAL, 150 MG CAPECITABINE, ORAL, 150 MG CAPECITABINE, 500 MG, ORAL CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CAPECITABINE, ORAL, 500 MG CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 50 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS Earliest Start Date 10/01/2003 07/15/2003 10/01/2003 07/15/2003 07/15/2003 07/15/2003 01/20/2005 04/19/2004 05/01/2005 01/20/2005 01/20/2005 03/17/2004 01/20/2005 01/05/2004 03/17/2004 04/19/2004 03/29/2004 05/01/2005 01/29/2008 01/01/2005 07/01/2006 01/01/2005 01/01/2005 07/01/2006 01/01/2005 07/24/2006 07/24/2006 01/01/2005 08/22/2007 10/24/2005 06/29/2005 08/03/2006 03/04/2008 06/24/2005 01/01/2000 03/07/2007 05/01/2008 01/01/2006 01/01/2006 06/03/2008 10/01/2003 02/10/2005 08/08/2007 10/19/2005 05/19/2006 10/01/2003 07/15/2005 06/28/2005 06/29/2005 06/29/2005 10/07/2005 01/12/2006 01/12/2006 01/11/2006 01/12/2006 01/20/2006 08/16/2006 01/01/1994 01/01/1994 03/28/2000 03/28/2000 03/28/2000 03/28/2000 01/18/2006 04/13/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/14/2009 02/14/2009 12/31/2078 12/31/2078 11/30/2005 08/31/2005 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8530 J8530 J8530 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 54868521800 54868521801 54868521802 00006006368 00054317644 00054317757 00054317763 00054417925 00054418025 00054418125 00054418225 00054418325 00054418425 00054817425 00054817525 00054817625 00054817925 00054818025 00054818125 00095008635 00095008651 18837003730 21695038204 23490540401 23490540701 23490540702 35356035930 49999005906 52959039212 52959039221 52959039228 52959054704 52959054710 52959054711 52959054712 52959054716 52959054720 52959054730 52959054750 54569032200 54569032203 54569032404 54569033601 54569572900 54868021800 54868021801 54868021803 54868021804 54868021805 54868021806 54868021807 54868021808 54868021809 54868091600 54868174400 54868315700 54868315701 54868533400 54868533401 55045130801 55045130802 55045130803 55045130806 55045130807 55045130808 12/19/2013 HCPCS Description CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL CYCLOPHOSPHAMIDE, 25 MG, ORAL DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG Earliest Start Date 02/10/2005 12/22/2005 12/22/2005 01/01/2006 01/01/2006 07/31/2008 09/30/1990 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 09/01/2006 01/01/2006 09/01/2006 02/01/2007 02/07/2007 02/07/2007 11/30/2007 08/08/2008 01/01/2006 01/01/2006 01/01/2006 01/01/2006 05/16/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 09/11/2006 04/03/2008 01/01/2006 01/01/2006 01/01/2006 05/10/2007 01/01/2006 08/31/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8540 J8560 J8560 J8560 J8561 J8561 J8561 55045130809 55045197005 55045266502 55289058204 55289058210 55887016530 55887016560 55887016590 55887037712 58016029000 58016029002 58016029003 58016029012 58016029015 58016029020 58016029030 58016029073 58016029089 58016029160 58016029300 58016029306 58016029312 58016029315 58016029320 58016029330 58016035020 58016078100 58016078108 58016078110 58016078112 58016078114 58016078115 58016078120 58016078121 58016078124 58016078128 58016078130 58016078140 58016078150 58468021802 60432046608 63874044401 63874044412 63874044415 63874044420 63874044421 63874044430 66267006612 66336047906 66336047915 66336055012 68115009612 68115009614 68115009630 68115009704 68115009715 68115009720 68115009730 68115043510 00378326694 54868535501 54868535502 00078041420 00078041461 00078041520 12/19/2013 HCPCS Description DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 DEXAMETHASONE, ORAL, 0.25 ETOPOSIDE, 50 MG, ORAL ETOPOSIDE, 50 MG, ORAL ETOPOSIDE, 50 MG, ORAL EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 01/01/2006 01/01/2006 01/01/2006 10/01/2007 04/10/2008 04/01/2007 04/01/2007 04/01/2007 03/23/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2007 01/01/2006 01/01/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2007 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 04/01/2010 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 10/19/2001 01/30/2006 01/30/2006 01/01/2012 01/01/2012 01/01/2012 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8561 J8561 J8561 J8565 J8600 J8600 J8600 J8600 J8600 J8600 J8600 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8610 J8650 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 00078041561 00078041720 00078041761 00310048230 00173004535 54868433900 54868433901 54868433902 54868433903 54868433904 59572030250 00054455015 00054455025 00054855025 00378001401 00378001450 00555057202 00555057235 23490588900 49999038024 51079067001 51079067005 51285036601 51285036701 51285036801 51285036901 51552105401 51552105409 51927156500 52959024400 54569181808 54868382600 54868382601 54868382602 54868382603 54868382604 54868382605 54868382606 54868382607 54868382608 54868382609 55289092430 60429008036 63370015410 63370015415 63370015425 63629147201 63629147202 67253032010 67253032036 67253058042 67253058043 67253058044 67253058045 67253058046 68115063200 00187024701 00085124803 00085136601 00085136602 00085141701 00085142501 00085142502 00085143001 00085143002 12/19/2013 HCPCS Description EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG EVEROLIMUS, ORAL, 0.25 MG GEFITINIB, ORAL, 250 MG MELPHALAN, 2 MG, ORAL MELPHALAN, 2 MG, ORAL MELPHALAN, 2 MG, ORAL MELPHALAN, 2 MG, ORAL MELPHALAN, 2 MG, ORAL MELPHALAN, 2 MG, ORAL MELPHALAN, 2 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE,2. 5 MG METHOTREXATE, 2.5 MG METHOTREXATE, 2.5 MG METHOTREXATE, 2.5 MG METHOTREXATE; ORAL, 2.5 MG METHOTREXATE; ORAL, 2.5 MG METHOTREXATE; ORAL, 2.5 MG METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE; ORAL, 2.5 MG METHOTREXATE; ORAL, 2.5 MG METHOTREXATE, 2.5 MG, ORAL METHOTREXATE; ORAL, 2.5 MG METHOTREXATE; ORAL, 2.5 MG METHOTREXATE; ORAL, 2.5 MG METHOTREXATE; ORAL, 2.5 MG METHOTREXATE, 2.5 MG, ORAL METHOTREXATE; ORAL, 2.5 MG METHOTREXATE, 2.5 MG, ORAL MTX 2.5MG ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL METHOTREXATE, 2.5 MG, ORAL NABILONE, ORAL, 1 MG TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL Earliest Start Date 01/01/2012 01/01/2012 01/01/2012 01/01/2005 01/01/1994 08/16/2005 11/22/2005 02/03/2006 04/03/2006 02/05/2008 04/22/2004 09/27/1994 09/27/1994 09/27/1994 01/01/1994 02/23/1998 01/01/1994 01/01/1994 11/30/2007 06/09/2004 01/01/1994 01/01/1994 03/09/2006 03/09/2006 12/01/2005 12/01/2005 09/01/2003 09/01/2003 09/08/2003 10/02/2000 10/20/2000 12/04/2002 12/04/2002 12/09/2002 08/25/2003 08/25/2003 07/20/2004 11/22/2004 11/04/2005 06/29/2010 09/13/2010 11/01/2005 05/25/2010 07/08/2003 07/08/2003 07/08/2003 11/01/2004 02/01/2009 12/30/2005 07/01/2009 07/01/2003 07/01/2003 07/01/2003 07/01/2003 07/01/2003 04/19/2004 01/01/2007 04/09/2007 04/09/2007 04/09/2007 04/09/2007 04/09/2007 04/09/2007 04/09/2007 04/09/2007 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8700 J8705 J8705 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 00085151901 00085151902 00085300401 00085300402 54868414200 54868414201 54868414202 54868414203 54868414204 54868414205 54868414206 54868534800 54868534801 54868535000 54868535001 54868535002 54868535003 54868535004 54868535400 54868535500 00007420511 00007420711 00003083050 00003633517 00003633617 00003633717 00007420511 00007420711 00009766304 00015050842 00015303020 00015303120 00015303220 00015303410 00024582005 00024582020 00054354258 00054458111 00054458127 00054460325 00054460425 00054483121 00054483126 00054483413 00054483422 00054860325 00054860425 00054883125 00054883425 00093078201 00093078205 00093078210 00093078256 00093078405 00093078406 00093078410 00093078486 00093551006 00093963487 00121477610 00172496058 00172496070 00172565649 00172565658 00172565670 12/19/2013 Earliest Start Date HCPCS Description TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TEMODAR, 5 MG, ORAL TOPOTECAN, ORAL, 0.25 MG TOPOTECAN, ORAL, 0.25 MG PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS 04/09/2007 04/09/2007 01/30/2008 01/30/2008 06/29/2005 08/03/2006 01/26/2006 03/16/2006 03/23/2006 03/23/2006 05/16/2006 10/20/2005 04/13/2006 10/31/2007 10/20/2005 11/22/2005 02/08/2006 03/23/2006 04/13/2006 12/20/2005 07/01/2009 07/01/2009 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/16/2008 09/16/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/12/2009 11/12/2009 04/11/2002 02/19/2004 02/19/2004 01/01/2002 01/01/2002 02/21/2003 02/21/2003 02/21/2003 02/21/2003 01/01/2002 01/01/2002 02/21/2003 02/21/2003 02/20/2003 01/09/2008 01/09/2008 02/20/2003 01/09/2008 02/20/2003 01/09/2008 02/20/2003 04/27/2005 08/13/2003 07/07/2006 01/01/2002 01/01/2002 02/20/2003 02/20/2003 02/20/2003 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/15/2015 04/15/2015 06/30/2013 10/14/2008 12/31/2078 10/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2008 03/31/2008 11/30/2008 11/30/2008 12/31/2078 12/31/2078 03/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2012 12/31/2078 12/31/2078 12/31/2078 03/31/2009 04/30/2009 12/31/2078 Page 1 of 1 HCPCS NDC J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 00172565680 00172565746 00172565760 00172565770 00172565780 00173063535 00182186489 00185112505 00185112518 00185112588 00310020130 00310020137 00378014405 00378014491 00378027401 00378027493 00378354725 00378354752 00555044609 00555044663 00555060602 00555060702 00555060704 00555087004 00555087063 00555088202 00555090401 00555090414 00904357161 12280034630 13632012301 49884028901 49884029001 49884029004 49884029005 49884072401 49884075305 49884075313 49884090738 49884090761 49884092202 49884092204 49999098630 51079043401 51079043420 51079043501 51079043519 51079043520 52959092830 54482005301 54569376501 54569571500 54569571600 54569573100 54569573200 54569585700 54868112600 54868112601 54868112602 54868112603 54868112604 54868112605 54868136600 54868136700 54868162900 12/19/2013 HCPCS Description PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, DRUG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, CHEMOTHERAPEUTIC, NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS NOS Earliest Start Date 02/20/2003 02/11/2004 02/20/2003 02/20/2003 04/28/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/02/2008 02/20/2003 02/20/2003 02/20/2003 02/20/2003 07/01/2005 07/01/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/09/2008 07/10/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/26/2006 01/26/2006 01/01/2002 05/01/2004 02/09/2004 11/18/2004 06/14/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/15/2008 01/01/2002 10/20/2005 07/15/2005 07/15/2005 08/03/2005 08/03/2005 11/06/2006 08/11/2003 11/22/2005 11/22/2005 11/22/2005 05/23/2006 10/17/2006 04/06/2006 08/08/2003 10/03/2005 Latest End Date 12/31/2078 12/31/2078 05/31/2009 05/31/2009 05/31/2009 06/30/2014 02/28/2010 08/31/2011 07/31/2011 12/31/2078 12/31/2078 07/29/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2011 11/30/2010 12/31/2078 12/31/2078 12/31/2015 12/31/2078 08/31/2011 12/31/2078 11/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J8999 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 54868162901 54868162902 54868300401 54868300402 54868300403 54868300404 54868300405 54868309901 54868428700 54868428701 54868428702 54868428703 54868428704 54868462800 54868477300 54868477301 54868477302 54868477303 54868500000 54868526100 54868528200 54868528201 54868538900 54868538901 57844052206 57866443601 57866482201 58016017000 58016017030 58016017060 58016017090 58016017099 60432012608 60432012616 60505036801 63629126201 63739016501 63739016503 63739016510 63739016515 63739026910 63739026915 66105083201 66105083203 66105083206 66105083209 66105083210 68094051859 68094051861 68094051862 68094052859 68094052861 68094052862 00069303020 00069303120 00069303220 00069303320 00069303420 00703504001 00703504303 00703504601 10019092001 10019092102 25021020705 25021020725 12/19/2013 HCPCS Description PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG Earliest Start Date 10/03/2005 07/06/2007 01/01/2002 01/01/2002 02/02/2006 04/10/2006 04/13/2006 01/01/2002 01/17/2005 01/17/2005 02/14/2005 09/22/2005 01/18/2008 06/12/2002 04/10/2003 08/06/2003 07/07/2005 07/14/2005 02/19/2004 06/29/2005 05/23/2005 05/23/2005 09/01/2005 12/14/2005 05/14/2004 04/15/2002 04/15/2002 02/01/2006 02/01/2006 02/01/2006 02/01/2006 02/01/2006 11/17/2004 12/01/2006 06/23/2006 11/01/2004 01/01/2002 01/01/2002 02/27/2007 06/09/2004 02/27/2007 02/15/2005 09/13/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 07/01/2007 11/28/2006 11/28/2006 07/01/2007 02/26/2004 02/26/2004 05/19/2011 05/19/2011 05/19/2011 05/19/2011 05/19/2011 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/01/2013 11/01/2013 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2007 01/31/2007 12/31/2078 07/01/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/17/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2007 06/30/2008 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9000 J9001 J9001 J9001 J9002 J9002 J9002 J9010 J9010 J9015 J9015 J9015 J9017 J9017 J9017 J9017 J9017 J9017 J9017 J9017 J9019 J9019 J9020 J9020 J9025 J9025 J9027 J9027 J9031 J9031 J9031 J9033 J9035 J9035 J9040 J9040 J9040 J9040 J9040 J9040 J9040 J9040 J9040 J9040 J9040 J9041 J9042 J9043 25021020751 55390023110 55390023210 55390023301 55390023510 55390023610 55390023701 55390023801 55390024110 55390024301 55390024510 55390024610 55390024701 55390024801 63323010161 63323088305 63323088310 63323088330 17314960001 17314960002 59676096001 17314960001 17314960002 59676096001 50419035703 58468035703 00078049561 53905099101 54868559600 10106006101 10106006104 10106006201 10106006204 49452073501 49452073502 51927144100 63459060010 57902024901 57902024905 57902024901 57902024905 59572010201 67211010201 58468010001 58468010002 00052060202 00052060302 49281088001 63459039120 50242006001 50242006101 00015301020 00015306301 00703315401 00703315491 00703315501 00703315591 55390000501 55390000601 61703032322 61703033218 63323013610 63020004901 51144005001 00024582411 12/19/2013 HCPCS Description INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS DOXORUBICIN, PER 10MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL DOXIL, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL DOXIL, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL DOXIL, 10 MG INJECTION, ALEMTUZUMAB, 10 MG ALEMTUZUMAB, PER 10MG INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ARSENIC TRIOXIDE, 1 MG INJECTION, ASPARAGINASE, 1,000 UNITS INJECTION, ASPARAGINASE, 1,000 UNITS INJECTION, ASPARAGINASE, 10,000 UNITS INJECTION, ASPARAGINASE, 10,000 UNITS AZACITADINE, PER 1 MG, INJECTION INJECTION, AZACITIDINE, 1 MG INJECTION, CLOFARABINE, 1 MG INJECTION, CLOFARABINE, 1 MG BCG (INTRAVESICAL) PER INSTILLATION BCG (INTRAVESICAL) PER INSTILLATION BCG (INTRAVESICAL) PER INSTILLATION BENDAMUSTINE HCL, PER 1MG INJECTION, BEVACIZUMAB, 10 MG INJECTION, BEVACIZUMAB, 10 MG INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN PER 15 UNITS INJECTION, BORTEZOMIB, 0.1 MG INJECTION, BRENTUXIMAB VEDOTIN, 1MG INJECTION, CABAZITAXEL, 1MG Earliest Start Date 11/01/2013 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/06/2007 08/06/2007 08/06/2007 08/06/2007 01/01/2002 01/01/2002 07/01/2011 01/01/2012 01/01/2012 07/01/2011 01/28/2005 01/25/2005 12/12/2007 01/01/2002 05/22/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 11/15/2004 11/15/2004 12/04/2003 07/15/2006 01/01/2013 01/01/2013 11/21/2011 11/21/2011 01/01/2010 01/01/2006 01/01/2006 01/01/2006 01/01/2002 01/01/2002 01/01/2002 03/31/2008 01/01/2005 01/01/2005 01/01/2002 01/01/2002 01/01/2002 02/20/2002 01/01/2002 02/20/2002 03/10/2003 03/10/2003 01/01/2002 01/01/2002 02/16/2009 01/01/2005 01/01/2013 01/01/2012 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2012 12/31/2078 12/31/2078 12/31/2078 06/30/2014 05/31/2014 09/30/2012 01/31/2013 01/31/2013 11/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/01/2012 06/01/2012 12/31/2078 06/01/2012 06/01/2012 12/31/2078 09/30/2011 12/31/2078 03/31/2012 12/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2009 02/28/2009 12/31/2078 04/30/2010 12/31/2078 01/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 J9045 00015321030 00015321130 00015321230 00015321330 00015321430 00015321530 00015321630 00409112910 00409112911 00409112912 00591333626 00591333712 00591333889 00591345460 00703324411 00703324611 00703324811 00703324911 00703326401 00703326601 00703326801 00703326871 00703327401 00703327601 00703327801 00703424401 00703424601 00703424801 10019091501 10019091701 10139006005 10139006015 10139006045 15210006112 15210006312 15210006612 15210006712 50111096576 50111096676 50111096776 55390015001 55390015101 55390015201 55390015301 55390015401 55390015501 55390015601 55390022001 55390022101 55390022201 61703033918 61703033922 61703033950 61703033956 61703036018 61703036022 61703036050 63323016610 63323016721 63323016800 63323017245 63323017260 67817006112 67817006312 67817006612 12/19/2013 HCPCS Description INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, INJECTION, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, CARBOPLATIN, 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 08/21/2003 08/21/2003 08/21/2003 01/01/2002 01/01/2002 01/01/2002 02/25/2004 12/11/2006 12/11/2006 12/11/2006 01/19/2007 01/19/2007 01/19/2007 01/19/2007 06/24/2004 06/24/2004 06/24/2004 11/17/2005 06/24/2004 06/24/2004 06/24/2004 05/01/2006 05/01/2006 05/01/2006 05/01/2006 05/01/2006 05/01/2006 02/01/2006 10/15/2004 10/15/2004 07/09/2007 07/09/2007 07/09/2007 01/15/2007 01/15/2007 01/15/2007 01/15/2007 02/01/2005 02/01/2005 02/01/2005 01/17/2006 01/17/2006 01/17/2006 10/15/2004 10/15/2004 10/15/2004 03/01/2006 11/19/2004 11/19/2004 11/19/2004 04/14/2004 04/14/2004 04/14/2004 02/09/2005 06/28/2006 06/28/2006 06/28/2006 04/01/2004 04/01/2004 04/01/2004 04/28/2006 04/07/2006 10/14/2004 10/14/2004 10/14/2004 Latest End Date 09/30/2007 06/30/2007 09/30/2007 03/31/2008 05/14/2008 04/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2009 03/30/2009 04/30/2009 03/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2008 05/31/2008 04/30/2008 09/30/2007 05/31/2009 02/28/2010 08/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2006 03/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2010 10/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9045 J9050 J9050 J9055 J9055 J9060 J9060 J9060 J9060 J9060 J9060 J9060 J9060 J9062 J9062 J9062 J9062 J9062 J9062 J9062 J9062 J9062 J9062 J9062 J9065 J9065 J9065 J9065 J9065 J9070 J9070 J9070 J9070 J9080 J9080 J9080 J9080 J9090 J9090 J9090 J9090 J9090 J9091 J9091 J9091 J9091 J9091 J9092 J9092 J9092 J9092 J9092 J9093 J9094 J9095 J9095 J9096 J9096 J9096 J9096 J9096 J9097 J9098 J9100 J9100 67817006712 00015301238 00015301260 66733094823 66733095823 00703574711 00703574811 49452207801 55390041450 55390041499 63323010351 63323010364 63323010365 00703574711 00703574811 55390009901 55390011250 55390011299 55390018701 55390041450 55390041499 63323010351 63323010364 63323010365 00069020101 55390011501 55390012401 59676020101 63323014010 00015050641 10019095501 10019095601 10019095701 00015050641 10019095501 10019095601 10019095701 00015050241 00015050641 10019095501 10019095601 10019095701 00015050541 00015050641 10019095501 10019095601 10019095701 00015050641 10019095501 10019095601 10019095701 10019095711 00015050641 00015050641 00015050241 00015050641 00015050541 00015050641 38779050603 38779050604 38779050605 00015050641 57665033101 55390013110 55390013210 12/19/2013 Earliest Start Date HCPCS Description INJECTION, CARBOPLATIN, 50 MG INJECTION, CARMUSTINE, 100 MG INJECTION, CARMUSTINE, 100 MG INJECTION, CETUXIMAB, 10 MG INJECTION, CETUXIMAB, 10 MG CISPLATIN PWD OR SOLN, PER 10MG INJECTION, CISPLATIN, POWDER OR SOLUTION, CISPLATIN, POWDER OR S0LUTION, PER 10 MG INJECTION, CISPLATIN, POWDER OR SOLUTION, INJECTION, CISPLATIN, POWDER OR SOLUTION, INJECTION, CISPLATIN, POWDER OR SOLUTION, INJECTION, CISPLATIN, POWDER OR SOLUTION, CISPLATIN PWD OR SOLN, PER 10MG CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ CISPLATIN 50MG INJ INJECTION, CLADRIBINE, PER 1 MG INJECTION, CLADRIBINE, PER 1 MG INJECTION, CLADRIBINE, PER 1 MG INJECTION, CLADRIBINE, PER 1 MG INJECTION, CLADRIBINE, PER 1 MG CYCLOPHOSPHAMIDE, 100MG CYCLOPHOSPHAMIDE 100MG CYCLOPHOSPHAMIDE 100MG CYCLOPHOSPHAMIDE 100MG INJ CYCLOPHOSPHAMIDE, 200 MG CYCLOPHOSPHAMIDE 200 MG CYCLOPHOSPHAMIDE 200 MG CYCLOPHOSPHAMIDE 200 MG CYCLOPHOSPHAMIDE 500MG CYCLOPHOSPHAMIDE, 500 MG CYCLOPHOSPHAMIDE, 500 MG CYCLOPHOSPHAMIDE 500MG CYCLOPHOSPHAMIDE 500MG CYCLOPHOSPHAMIDE 1GM CYCLOPHOSPHAMIDE, 1 GM CYCLOPHOSPHAMIDE 1000MG CYCLOPHOSPHAMIDE, 1.0 GRAM CYCLOPHOSPHAMIDE 1.0 GM INJ CYCLOPHOSPHAMIDE, 2 GM CYCLOPHOSPHAMIDE 2.0 GM INJ CYCLOPHOSPHAMIDE 2.0 GM INJ CYCLOPHOSPHAMIDE, 2.0 GRAM CYCLOPHOSPHAMIDE, 2.0 GRAM CYCLOPHOSPHAMIDE, 100MG CYCLOPHOSPHAMIDE, 200MG CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG CYCLOPHOSPHAMIDE, 500 MG CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM 1 GM CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM CYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 GRAM INJECTION, CYTARABINE LIPOSOME, 10 MG INJECTION, CYTARABINE, 100 MG CYTARABINE, 100MG 10 MG 10 10 10 10 MG MG MG MG 10/14/2004 01/01/2002 04/07/2008 01/01/2005 05/03/2007 12/31/1999 06/01/2000 01/30/2002 10/09/2001 10/09/2001 11/15/1999 11/15/1999 12/31/1999 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/14/2013 01/01/2002 01/01/2002 01/01/2002 09/13/2004 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2007 01/01/2006 04/30/2004 01/01/2006 01/01/2006 01/01/2007 01/01/2006 01/01/2006 04/30/2004 01/01/2006 01/01/2006 01/01/2006 01/01/2006 04/30/2004 04/30/2004 01/01/2006 01/01/2006 05/15/2004 01/01/2006 05/15/2004 01/01/2006 01/01/2002 01/01/2002 01/01/2002 05/15/2004 01/01/2004 01/01/2002 07/01/1996 Latest End Date 12/31/2078 09/30/2009 09/30/2015 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2012 12/31/2078 10/01/2012 12/31/2078 08/31/2010 12/31/2078 12/31/2078 12/31/2078 08/31/2010 12/31/2078 12/31/2078 12/31/2078 10/31/2010 08/31/2010 12/31/2078 12/31/2078 12/31/2078 11/30/2010 08/31/2010 12/31/2078 12/31/2078 12/31/2078 08/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2010 08/31/2010 10/31/2010 08/31/2010 11/30/2010 08/31/2010 12/31/2078 12/31/2078 12/31/2078 08/31/2010 12/31/2078 12/31/2078 11/30/2012 Page 1 of 1 HCPCS NDC J9100 J9100 J9100 J9100 J9110 J9110 J9110 J9110 J9110 J9110 J9110 J9110 J9110 J9110 J9110 J9110 J9110 J9120 J9130 J9130 J9140 J9140 J9140 J9140 J9140 J9140 J9140 J9140 J9140 J9150 J9150 J9150 J9150 J9150 J9150 J9150 J9150 J9151 J9155 J9155 J9160 J9160 J9170 J9170 J9170 J9171 J9171 J9171 J9171 J9171 J9171 J9171 J9171 J9171 J9171 J9171 J9171 J9175 J9178 J9178 J9178 J9178 J9178 J9178 J9178 55390013301 55390080610 61703030538 61703031922 55390013110 55390013210 55390013301 55390013401 55390080710 55390080801 55390080901 61703030346 61703030350 61703030425 61703030436 61703031922 63323012020 67386081155 61703032722 63323012710 00026815120 00703507501 00703507503 51927236200 55390009010 55390033910 61703032722 63323012812 63323012820 00703523313 55390010801 55390010810 55390014210 55390028110 55390080510 63323011908 63323012404 61958030101 55566830101 55566840101 62856060301 64365050301 00075800120 00075800180 16729022850 00075800120 00075800180 00075800301 00075800404 00409020102 00409020110 00409020120 00955102001 00955102104 16729012049 16729022850 66758005001 67871000710 00009509101 00009509301 00591346983 00591347057 00703306711 00703306911 10139006101 12/19/2013 HCPCS Description CYTARABINE, PER 100MG INJ INJECTION, CYTARABINE, 100 MG INJECTION, CYTARABINE, 100 MG CYTARABINE, 100MG CYTARABINE, 500MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, CYTARABINE, 500 MG INJECTION, DACTINOMYCIN, 0.5 MG DACARBAZINE 100MG DACARBAZINE, 100 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG DACARBAZINE, 200 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 M INJECTION, DEGARELIX, 1MG INJECTION, DEGARELIX, 1MG INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS INJECTION, DOCETAXEL, 20 MG INJECTION, DOCETAXEL, 20 MG DOCETAXEL, PER 20MG INJECTION, DOCETAXEL, 1 MG INJECTION, DOCETAXEL, 1 MG DOCETAXEL, PER 1MG DOCETAXEL, PER 1MG DOCETAXEL, PER 1MG DOCETAXEL, PER 1MG DOCETAXEL, PER 1MG DOCETAXEL, PER 1MG INJECTION, DOCETAXEL, 1 MG DOCETAXEL, PER 1MG DOCETAXEL, PER 1MG DOCETAXEL, PER 1MG INJECTION, ELLIOTTS' B SOLUTION, 1 ML INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG Earliest Start Date 01/01/2011 01/01/2002 05/01/2003 07/01/1996 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 05/01/2003 01/01/2002 01/01/2002 05/01/2003 01/01/2002 03/05/2004 01/21/2006 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/08/2003 01/01/2002 03/05/2008 09/23/2002 01/01/2002 01/01/2002 01/27/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/18/2004 01/01/2002 01/01/2012 01/01/2012 01/17/2008 01/01/2002 01/01/2002 01/01/2002 06/30/2011 01/01/2010 01/01/2010 10/11/2010 10/11/2010 03/17/2011 03/17/2011 03/17/2011 03/14/2011 03/14/2011 06/30/2011 06/30/2011 08/05/2011 01/01/2006 01/01/2004 01/01/2004 10/23/2007 10/23/2007 08/09/2007 08/09/2007 11/30/2007 Latest End Date 12/31/2078 07/31/2013 12/31/2078 12/31/2078 12/31/2078 11/30/2012 12/31/2078 12/31/2078 03/31/2013 08/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2006 12/31/2078 12/31/2078 12/31/2078 11/30/2012 02/29/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2012 12/31/2078 04/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/01/2009 05/31/2012 06/30/2013 12/31/2078 05/31/2012 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9178 J9179 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9181 J9182 J9182 J9182 J9182 J9182 J9182 J9182 J9182 J9182 J9182 J9185 J9185 J9185 J9185 J9185 J9185 J9185 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 10139006125 10518010410 10518010411 25021020325 55390020701 55390020801 59762509101 59762509301 61703034735 61703034859 61703035901 61703035902 61703035959 61703035991 61703035992 61703035993 63323015100 63323015105 63323015125 63323015175 62856038901 00015340420 00703565301 00703565601 00703565701 10019093001 10019093002 16729011431 51927277200 55390029101 55390029201 55390029301 55390049101 55390049201 55390049301 63323010405 63323010425 63323010450 00703565301 00703565601 00703565701 38779078403 38779078406 51927277200 55390029101 55390029301 63323010405 63323010450 00703485211 00703485281 00703585401 50419051106 63323019002 63323019606 66758004601 00187395364 00703301513 00703301812 00703301912 10139006301 10139006311 10139006312 10139006350 38779002501 38779002504 12/19/2013 HCPCS Description INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG EPIRUBICIN PER 2MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, ERIBULIN MESYLATE, 0.1 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 100MG ETOPOSIDE 100MG ETOPOSIDE 100MG ETOPOSIDE, 100 MG ETOPOSIDE, 100 MG ETOPOSIDE, 100 MG ETOPOSIDE 100MG ETOPOSIDE 100MG ETOPOSIDE 100MG ETOPOSIDE 100MG INJECTION, FLUDARABINE PHOSPHATE, 50 INJECTION, FLUDARABINE PHOSPHATE, 50 INJECTION, FLUDARABINE PHOSPHATE, 50 INJECTION, FLUDARABINE PHOSPHATE, 50 INJECTION, FLUDARABINE PHOSPHATE, 50 INJECTION, FLUDARABINE PHOSPHATE, 50 INJECTION, FLUDARABINE PHOSPHATE, 50 INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG MG MG MG MG MG MG MG Earliest Start Date 11/30/2007 08/24/2007 08/24/2007 08/24/2009 08/07/2007 08/07/2007 08/08/2007 08/08/2007 11/06/2006 11/06/2006 04/10/2008 04/10/2008 08/08/2007 03/13/2008 03/13/2008 08/08/2007 12/07/2007 12/07/2007 12/07/2007 12/07/2007 01/01/2012 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 03/22/2011 01/01/2009 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2006 04/25/2002 04/25/2002 09/08/2003 01/01/2007 01/01/2007 01/01/2006 01/01/2007 05/02/2007 08/03/2006 09/12/2003 01/01/2002 10/31/2007 12/07/2007 10/12/2007 01/01/2002 09/02/2003 09/02/2003 09/02/2003 07/02/2007 06/11/2007 06/11/2007 06/07/2007 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2011 10/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2013 05/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/30/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9190 J9200 J9200 J9200 J9200 J9201 J9201 J9201 J9201 J9201 J9201 J9201 J9201 J9201 J9202 J9202 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9206 J9207 J9208 38779002505 49452317501 49452317502 49452317503 49452317504 51552073301 51552073302 51552073304 51552073305 51927108500 62991148601 62991148602 62991148603 63323011710 63323011720 63323011751 63323011761 63370009515 63370009525 63370009535 66758004403 55390013501 55390043501 61703033109 63323014507 00002750101 00002750201 00409018101 00409018601 00781328275 00781328379 63323010210 63323010213 63323012550 00310095036 00310095130 00009752901 00009752902 00009752903 00009752904 00009752905 00591318902 00591318926 00703443211 00703443411 00781306672 00781306675 10019093401 10019093402 10019093417 10019093479 10518010310 10518010311 18111000202 18111000203 59762752901 59762752902 61703034909 61703034916 61703034936 63323019302 63323019305 66758004802 00015191012 00015055605 12/19/2013 HCPCS Description INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG 5FU PER 500MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUOROURACIL, 500 MG 500MG INJ FLUOROURACIL INJECTION, FLOXURIDINE, 500 MG INJECTION, FLOXURIDINE, 500 MG INJECTION, FLOXURIDINE, 500 MG INJECTION, FLOXURIDINE, 500 MG INJECTION, GEMCITABINE HYDROCHLORIDE, INJECTION, GEMCITABINE HYDROCHLORIDE, GEMICITABINE, 200MG GEMICITABINE, 200MG INJECTION, GEMCITABINE HYDROCHLORIDE, INJECTION, GEMCITABINE HYDROCHLORIDE, GEMICITABINE, 200MG GEMICITABINE, 200MG GEMICITABINE, 200MG GOSERELIN ACETATE IMPLANT, PER 3.6 MG GOSERELIN ACETATE IMPLANT, PER 3.6 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG IRINOTECAN, PER 20MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IRINOTECAN, 20 MG IRINOTECAN, 20 MG/ML IXABEPILONE, PER 1MG INJECTION, IFOSFAMIDE, 1 GRAM 200 MG 200 MG 200 MG 200 MG Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2004 09/01/2003 09/01/2003 09/01/2003 09/01/2003 09/08/2003 08/17/2011 09/15/2003 09/15/2003 12/21/1998 01/01/2002 01/01/2002 01/01/2002 07/08/2003 07/08/2003 07/08/2003 07/01/2009 01/01/2002 01/01/2002 09/23/2002 01/01/2002 01/01/2002 01/01/2002 08/26/2011 08/26/2011 11/15/2010 11/15/2010 01/25/2011 01/25/2011 01/25/2011 05/05/2003 05/05/2003 01/01/2002 01/01/2002 10/01/2010 10/01/2010 07/26/1996 03/04/2008 03/04/2008 02/28/2008 02/28/2008 02/27/2008 02/27/2008 02/21/2008 02/21/2008 02/21/2008 02/21/2008 02/27/2008 02/27/2008 02/28/2008 02/28/2008 02/27/2008 02/27/2008 02/27/2008 02/27/2008 02/27/2008 02/05/2008 02/05/2008 12/23/2009 01/01/2009 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2014 05/31/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/01/2013 06/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2009 12/31/2009 12/31/2078 12/31/2078 06/30/2011 10/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/30/2010 12/31/2078 12/31/2078 02/01/2011 01/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2011 Page 1 of 1 HCPCS NDC J9208 J9208 J9208 J9208 J9208 J9208 J9208 J9208 J9208 J9209 J9209 J9209 J9209 J9209 J9209 J9209 J9209 J9209 J9209 J9209 J9209 J9211 J9211 J9211 J9211 J9211 J9211 J9211 J9211 J9211 J9211 J9211 J9211 J9212 J9212 J9212 J9212 J9212 J9212 J9213 J9213 J9213 J9213 J9213 J9213 J9214 J9214 J9214 J9214 J9214 J9214 J9214 J9214 J9214 J9214 J9215 J9216 J9217 J9217 J9217 J9217 J9217 J9217 J9217 J9217 00015055741 00703342711 00703342911 10019092501 10019092582 10019092602 10019092616 63323014210 63323014212 00015356302 00015356303 00703480503 10019095301 10019095302 10019095362 55390004501 55390026601 55390034701 63323073310 63323073311 63323073312 00013257691 00013258691 00013259691 00703415411 00703415511 00703415611 55390021501 55390021601 55390021701 59762257601 59762258601 59762259601 00187200601 00187200605 00187200702 00187200706 64116003106 64116003906 00004201507 00004201509 00004201607 00004201609 00004201707 00004201709 00085053901 00085057102 00085111001 00085113301 00085116801 00085117902 00085123501 00085124201 00085125401 54868334100 54746000101 64116001112 00024022205 00024060545 00024061030 00024079375 00074334603 00074364203 00074366303 00074368303 12/19/2013 HCPCS Description INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, MESNA, 200 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 2 INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE DEPOT, 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE PER 7.5MG DEPOT SUSP LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG Earliest Start Date 01/01/2002 07/26/2007 07/26/2007 09/12/2005 05/05/2007 09/12/2005 05/05/2007 07/25/2002 11/18/2002 01/01/2002 01/01/2002 02/22/2002 03/15/2004 03/15/2004 05/05/2007 02/24/2004 09/21/2005 03/05/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/24/2002 09/24/2002 09/24/2002 08/07/2007 08/07/2007 08/07/2007 08/27/2007 08/27/2007 08/27/2007 01/18/2008 01/18/2008 01/18/2008 01/18/2008 04/18/2003 04/18/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/02/2003 01/01/2002 01/01/2002 11/01/2003 02/18/2005 03/04/2003 07/25/2003 01/01/2010 09/30/1998 09/30/1998 04/01/2009 Latest End Date 10/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 11/30/2010 11/30/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2012 07/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2011 12/31/2078 04/30/2012 06/30/2012 09/30/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2009 02/28/2009 12/31/2078 10/31/2008 12/31/2078 10/31/2008 12/31/2078 10/31/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2007 09/12/2012 09/12/2012 09/12/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9217 J9217 J9217 J9217 J9217 J9217 J9217 J9217 J9218 J9218 J9218 J9218 J9218 J9218 J9218 J9219 J9225 J9225 J9225 J9226 J9226 J9228 J9228 J9230 00300210801 00300228201 00300244001 00300334601 00300364201 00300366301 00300368301 54868556800 00185740085 00300361224 00300361228 00406805003 00703401418 00703401419 49884036826 00026971101 55592050001 67979000201 67979050001 67979000201 67979050001 00003232711 00003232822 67386091151 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE IMPLANT, 65 MG HISTRELIN IMPLANT, 50 MG HISTRELIN IMPLANT, 50 MG HISTRELIN IMPLANT, 50 MG HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG IPILMUMAB INJ, PER 1MG IPILMUMAB INJ, PER 1MG INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD) J9245 J9245 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9250 J9260 J9260 J9260 J9260 J9260 J9260 J9260 J9260 J9260 J9261 J9261 J9263 J9263 J9263 J9263 J9263 J9263 00173013093 59572030101 10139006202 10139006210 10139006240 54868017300 54868017301 54868471600 54868479600 54868480900 55390003110 55390003210 55390003310 55390003410 61703035038 61703040841 63323012102 63323012104 63323012108 63323012110 63323012140 63323012302 63323012310 55390003110 55390003210 55390003410 55390014301 61703035038 61703040841 63323012250 63323012302 63323012310 00007440101 00007440106 00024059010 00024059120 00024059240 00703398501 00703398601 61703036318 INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG METHOTREXATE SODIUM, 50 MG INJECTION, NELARABINE, 50 MG INJECTION, NELARABINE, 50 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, OXALIPLATIN, 0.5 MG OXALIPLATIN INJ, 0.5MG OXALIPLATIN INJ, 0.5MG OXALIPLATIN INJ, 0.5MG 12/19/2013 HCPCS Description Earliest Start Date Latest End Date 01/01/2002 03/15/2004 07/02/2007 06/07/2007 06/07/2007 03/26/2003 04/06/2005 12/16/2002 05/21/2003 06/03/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/27/2005 04/09/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/08/2002 01/01/2002 01/01/2002 09/07/2005 05/01/1996 09/07/2005 09/07/2005 01/01/2007 02/26/2001 01/01/2002 01/01/2007 01/01/2007 04/02/2008 01/01/2007 06/08/2005 06/08/2005 08/20/2007 01/01/2010 08/11/2009 08/10/2009 05/31/2012 03/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2013 12/31/2078 12/31/2078 12/31/2078 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/12/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/27/2006 01/01/2002 01/01/2006 06/18/2007 07/25/2007 01/01/2008 01/01/2008 01/01/2012 01/01/2012 01/21/2006 02/01/2011 08/01/2011 11/01/2010 07/01/2011 08/01/2011 10/01/2011 07/01/2011 12/31/2078 12/31/2012 11/01/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9263 J9263 J9264 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9265 J9266 J9266 J9268 J9268 J9268 J9280 J9280 J9280 J9290 J9290 J9290 J9290 J9290 J9290 J9290 J9290 J9290 J9291 J9291 J9291 J9291 J9293 J9293 J9293 J9293 J9293 61703036322 63323065020 68817013450 00015347530 00015347630 00015347911 00172375377 00172375396 00172375473 00172375494 00172375675 00172375695 00555198414 00555198514 00703476601 00703476701 00703476801 10518010207 10518010208 10518010209 55390011405 55390011420 55390011450 55390030405 55390030420 55390030450 55390031405 55390031420 55390031450 55390051405 55390051420 55390051450 61703034209 61703034222 61703034250 63323076350 66758004301 66758004302 66758004303 54482030101 57665000202 00409080101 55390024401 62701080001 16729010811 16729011505 55390025201 00015300220 38779055307 38779055309 49452478502 51927364200 55390025201 55390045201 62701001101 63323019140 00015305920 55390025201 55390025301 55390045301 00703468001 00703468091 00703468501 00703468591 00703468601 12/19/2013 HCPCS Description INJECTION, OXALIPLATIN, 0.5 MG OXALIPLATIN INJ, 0.5MG INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG PACLITAXIL, 6MG/ML INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL INJECTION, PENTOSTATIN, 10 MG INJECTION, PENTOSTATIN, 10 MG INJECTION, PENTOSTATIN, 10 MG MITOMYCIN PER 5MG MITOMYCIN PER 5MG MITOMYCIN, PER 5MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 20 MG MITOMYCIN, 40 MG MITOMYCIN 40 MG INJ MITOMYCIN, 40 MG MITOMYCIN, 40 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG Earliest Start Date 08/10/2009 06/14/2010 01/01/2006 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/24/2002 01/01/2002 01/24/2002 01/01/2002 01/24/2002 06/03/2008 06/03/2008 09/24/2008 09/15/2000 09/16/2009 04/19/2007 04/19/2007 04/19/2007 01/01/2002 01/01/2002 01/01/2002 12/04/2006 12/04/2006 12/04/2006 01/14/2004 01/14/2004 01/14/2004 01/25/2005 01/25/2005 01/25/2005 04/21/2004 04/21/2004 04/21/2004 05/04/2007 01/11/2008 01/11/2008 01/11/2008 03/08/2012 04/01/2002 07/20/2007 08/08/2007 01/01/2002 06/09/2009 06/18/2009 05/01/1996 01/01/2002 05/24/2002 05/29/2002 11/15/2004 08/19/2004 01/01/2002 01/01/2002 01/01/2002 02/04/2002 01/01/2002 01/01/2006 01/01/2002 01/01/2002 04/11/2006 11/06/2006 04/11/2006 11/06/2006 04/11/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 06/30/2010 07/31/2010 07/31/2010 06/30/2010 08/31/2008 07/31/2010 12/31/2078 05/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2011 11/30/2009 07/30/2010 12/31/2078 12/31/2078 12/31/2078 11/30/2012 04/30/2013 04/30/2013 03/31/2012 06/30/2012 12/31/2012 10/31/2009 12/31/2009 12/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/06/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/31/2012 12/31/2078 12/31/2078 12/31/2078 04/30/2009 12/31/2078 Page 1 of 1 HCPCS NDC J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9293 J9300 J9302 J9302 J9303 J9303 J9303 J9305 J9305 J9307 J9310 J9310 J9315 J9320 J9328 J9330 J9340 J9340 J9340 J9340 J9350 J9350 J9350 J9351 J9351 J9351 J9351 J9351 J9355 J9355 J9357 J9357 J9360 J9360 J9370 J9370 J9370 J9370 J9375 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 00703468691 15210040335 15210040336 15210040337 44087152001 44087152501 44087153001 55390008301 55390008401 55390008501 61703034318 61703034365 61703034366 63323013210 63323013212 63323013215 00008451001 00173082101 00173082133 55513095401 55513095501 55513095601 00002762301 00002764001 48818000101 50242005121 50242005306 59572098301 00703463601 00085138101 00008117901 00703430102 00703430301 51927276200 55390003010 00007420101 00007420105 55390037010 00409030201 25021020606 55390037010 63323076210 63323076217 50242005656 50242013468 67979000101 67979000102 55390009110 63323027810 00703440211 00703441211 61703030906 61703030916 00703441211 00703418201 00703418281 00703418291 00703418301 00703418381 00703418391 10019097001 10019097002 55390006901 55390007001 55390026701 12/19/2013 HCPCS Description INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, MITOXANTRONE HYDROCHLORIDE, PER INJECTION, GEMTUZUMAB OZOGAMICIN, 5 MG INJECTION, OFATUMUMAB, 10 MG INJECTION, OFATUMUMAB, 10 MG INJECTION, PANITUMUMAB, 10 MG INJECTION, PANITUMUMAB, 10 MG INJECTION, PANITUMUMAB, 10 MG INJECTION, PEMETREXED, 10 MG INJECTION, PEMETREXED, 10 MG INJECTION, PRALATREXATE, 1 MG INJECTION, RITUXIMAB, 100 MG INJECTION, RITUXIMAB, 100 MG INJECTION, ROMIDEPSIN, 1 MG INJECTION, STREPTOZOCIN, 1 GRAM INJECTION, TEMOZOLOMIDE, 1 MG INJECTION, TEMSIROLIMUS, 1 MG INJECTION, THIOTEPA, 15 MG INJECTION, THIOTEPA, 15 MG INJECTION, THIOTEPA, 15 MG INJECTION, THIOTEPA, 15 MG INJECTION, TOPOTECAN, 4 MG INJECTION, TOPOTECAN, 4 MG INJECTION, TOPOTECAN, 4 MG TOPOTECAN, PER 0.1MG INJECTION, TOPOTECAN, 0.1 MG INJECTION, TOPOTECAN, 0.1 MG INJECTION, TOPOTECAN, 0.1 MG INJECTION, TOPOTECAN, 0.1 MG TRASTUZUMAB, 10MG (HERCEPTIN) INJECTION, TRASTUZUMAB, 10 MG INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG INJECTION, VINBLASTINE SULFATE, 1 MG INJECTION, VINBLASTINE SULFATE, 1 MG VINCRISTINE SULFATE, 1 MG VINCRISTINE SULFATE, 1 MG VINCRISTINE SULFATE, 1 MG VINCRISTINE SULFATE, 1 MG VINCRISTINE SULFATE, 2MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG MG Earliest Start Date 11/06/2006 08/14/2006 07/31/2006 08/14/2006 06/11/2003 06/11/2003 06/11/2003 04/11/2006 04/11/2006 04/11/2006 04/11/2006 04/11/2006 04/11/2006 03/17/2006 03/17/2006 03/17/2006 01/01/2002 01/01/2012 01/01/2012 01/01/2008 01/01/2008 01/01/2008 01/01/2005 01/07/2008 10/05/2009 01/01/2002 01/01/2002 01/01/2012 12/03/2003 01/01/2012 06/27/2007 01/01/2002 01/01/2002 09/08/2003 01/01/2002 01/01/2002 01/01/2002 04/18/2011 02/21/2011 12/02/2010 04/18/2011 11/29/2010 11/29/2010 01/01/2006 09/01/2003 10/31/2007 10/31/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 02/10/2003 05/01/2006 05/01/2006 02/10/2003 05/01/2006 05/01/2006 12/01/2003 12/01/2003 02/03/2004 02/03/2004 09/21/2005 Latest End Date 11/30/2008 12/31/2078 12/31/2078 12/31/2078 11/30/2013 12/31/2007 12/31/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/28/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 05/31/2012 12/31/2078 12/31/2078 12/31/2012 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9390 J9395 J9395 J9395 J9600 J9999 J9999 J9999 J9999 J9999 J9999 J9999 J9999 J9999 J9999 J9999 J9999 P9047 Q0138 Q0138 Q0139 Q0139 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 55390026801 60831308601 60831308602 61703034106 61703034109 63323014801 63323014805 64370053201 64370053202 64370308601 64370308602 66758004501 66758004502 00310072010 00310072025 00310072050 58914015575 00015355427 00015355626 00015356415 00703410048 00703410058 00703410068 00703410948 00703410958 00703410968 55390010601 59730560101 67286005308 00944049301 59338077501 59338077510 59338077501 59338077510 00069305107 00069305175 00069306030 00069306075 00069306086 00069307030 00069307075 00069307086 00069308030 00069311019 00069312019 00069313019 00069314019 00069417021 00093714609 00093714618 00093714656 00093714756 00093714823 00093714994 00093716933 00093716956 00185720370 00185720670 00185720969 00185721268 00378153383 00378153459 00378153593 00781149631 00781149668 12/19/2013 Earliest Start Date HCPCS Description INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, VINORELBINE TARTRATE, 10 MG FULVESTRANT, PER 25MG INJECTION, FULVESTRANT, 25 MG INJECTION, FULVESTRANT, 25 MG INJECTION, PORFIMER SODIUM, 75 MG NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS HUMAN ALBUMIN 25%, PER 50 ML FERUMOXYTROL, PER 1MG (NON ESRD) FERUMOXYTROL, PER 1MG (NON ESRD) FERUMOXYTROL, PER 1MG (ESRD) FERUMOXYTROL, PER 1MG (ESRD) AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROYMCIN ORAL, 1GM AZITHROMYCIN ORAL PER 1GM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM 1 1 1 1 1 1 1 1 1 1 1 GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM 09/21/2005 12/19/2005 12/19/2005 09/07/2005 11/07/2005 06/22/2005 06/22/2005 06/23/2008 06/23/2008 03/26/2007 03/26/2007 03/05/2008 03/05/2008 10/01/2007 01/01/2004 01/01/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 04/08/2002 04/08/2002 04/08/2002 05/01/2006 05/01/2006 05/01/2006 09/01/2004 01/01/2002 06/10/2004 09/30/1990 01/01/2010 01/01/2010 01/01/2010 01/01/2010 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 08/06/2002 08/06/2002 10/21/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/11/2005 12/06/2005 11/14/2005 11/14/2005 11/14/2005 01/01/2009 09/22/2008 11/14/2005 11/14/2005 09/21/2006 09/21/2006 09/21/2006 09/21/2006 06/05/2007 06/05/2007 06/05/2007 01/09/2006 11/14/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/01/2011 07/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2010 12/31/2078 12/31/2078 06/30/2009 06/30/2009 03/31/2009 12/31/2078 12/31/2078 12/31/2078 04/30/2009 10/31/2009 10/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 06/28/2013 12/31/2078 06/28/2013 06/28/2013 08/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 00781149669 00781149731 00781194131 00781194133 12280005730 12280010930 12280026806 12280026903 13411013101 13411013103 13411013106 13411013109 13411013115 16590024806 16590036206 18837033806 21695001206 23490690401 23490690500 23490690501 23490690502 23490775801 23490776001 23490776002 33358004006 33358004110 33358036701 33358036703 33358036804 33358036830 33358036850 35356001703 35356004415 35356012815 49999009604 49999009606 49999026015 49999058215 49999078606 50111076728 50111078710 50111078752 50111078766 50111078810 50111078852 50111078867 50111078910 50111079120 50111079222 50111079320 51079059101 51079059120 52959031315 52959050506 52959065703 52959065706 52959083806 52959092703 52959093230 54569423000 54569423100 54569423200 54569441700 54569449700 54569452200 12/19/2013 HCPCS Description AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM Earliest Start Date 11/14/2005 11/14/2005 11/16/2005 11/16/2005 03/21/2005 03/24/2005 03/08/2006 03/08/2006 08/23/2006 06/01/2005 08/23/2006 08/23/2006 08/23/2006 02/01/2006 12/01/2006 04/15/2008 07/19/2007 11/12/2007 04/09/2007 10/11/2007 10/11/2007 02/07/2007 02/07/2007 04/09/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 09/14/2007 10/26/2007 03/13/2008 01/27/2006 08/08/2002 07/01/2003 01/27/2006 01/11/2006 07/06/2006 12/15/2005 08/10/2006 12/15/2005 12/15/2005 08/10/2006 12/15/2005 12/15/2005 07/06/2006 07/06/2006 07/06/2006 06/25/2007 06/25/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2006 11/22/2005 04/24/2008 05/23/2008 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 02/29/2012 06/30/2011 03/31/2012 12/31/2078 01/31/2012 12/31/2078 01/31/2012 09/30/2011 02/29/2012 02/29/2012 02/29/2012 07/31/2011 07/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 54569452201 54569452202 54569456700 54569544800 54569575400 54569575500 54569575600 54569577100 54569580400 54569580600 54569580700 54569580800 54569580900 54569581000 54868324400 54868364800 54868407600 54868407800 54868407801 54868407802 54868418300 54868464400 54868464401 54868464402 54868540400 54868547100 54868547800 54868547801 54868547802 54868548700 54868548701 54868564700 54868564800 54868564801 54868564802 55045237205 55045237305 55045237306 55045237308 55045249206 55045344206 55045369301 55045369803 55045372501 55045372602 55045372701 55289027402 55289027403 55289031004 55289031006 55289031014 55289096404 55289096414 55887003315 55887031130 55887078506 55887093306 57866044607 57866313601 57866435601 58016008600 58016008630 58016008660 58016008690 58016039100 12/19/2013 HCPCS Description AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, DIHYDRATE, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, CAPSULES/POWDER, 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM GRAM Earliest Start Date 01/01/2002 08/26/2002 01/01/2002 09/09/2002 11/24/2005 11/24/2005 11/24/2005 02/14/2006 06/30/2006 07/24/2006 07/24/2006 07/24/2006 07/24/2006 07/25/2006 06/08/2004 11/16/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 07/26/2002 02/21/2005 06/01/2005 09/02/2005 11/16/2005 11/23/2005 12/13/2005 02/07/2006 12/13/2005 08/10/2007 08/01/2006 08/01/2006 08/01/2006 08/03/2006 01/19/2005 01/19/2005 01/01/2003 01/19/2005 07/03/2006 12/05/2005 12/06/2006 12/26/2006 12/26/2006 12/26/2006 12/26/2006 10/16/2007 04/02/2008 01/01/2002 01/15/2004 01/01/2002 11/01/2005 02/01/2006 04/01/2008 01/01/2007 06/01/2007 01/01/2002 04/15/2002 05/01/2006 03/28/2006 02/01/2006 02/01/2006 02/01/2006 02/01/2006 01/15/2004 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0144 Q0162 Q0162 58016039101 58016039106 58016039110 58016039115 58016039118 58016039120 58016039128 58016039130 58016039160 58016039190 58016481401 58864065504 58864065506 58864065514 58864065530 58864079106 59762305101 59762305102 59762306001 59762306002 59762306003 59762307001 59762307002 59762308001 59762311001 59762312001 59762313001 59762314001 63874024600 63874024604 63874024606 63874024610 63874024615 64679096101 64679096104 64679096105 64679096201 64679096401 64679096403 64679096405 66105050701 66105050703 66105050706 66105050709 66105050710 66105065301 66105065303 66105065305 66105065306 66105065319 66105067001 66105067003 66105067005 66105067006 66105067018 66267092806 66336040005 66336046644 68115036404 68115036450 68115054150 68115093106 68387056506 00093723656 00143242330 12/19/2013 HCPCS Description AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI Earliest Start Date 04/03/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/15/2004 01/15/2004 12/20/2005 07/01/2005 09/10/2003 02/01/2005 06/01/2006 07/01/2004 07/07/2006 07/07/2006 11/14/2005 11/14/2005 11/14/2005 11/14/2005 11/14/2005 11/14/2005 07/07/2006 07/07/2006 07/07/2006 07/07/2006 03/15/2006 03/15/2006 03/15/2006 03/15/2006 03/15/2006 02/11/2008 02/14/2008 02/11/2008 02/11/2008 02/11/2008 02/14/2008 02/11/2008 08/22/2006 01/01/2006 08/22/2006 08/22/2006 08/22/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 09/13/2006 01/01/2002 12/03/2007 10/22/2004 10/26/2004 05/04/2005 05/04/2005 01/05/2004 05/01/2006 01/01/2012 01/01/2012 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 00173044600 00173044604 00173044700 00173044702 00173044704 00173048900 00173056900 00173057000 00378031553 00378031593 00378034453 00378034493 00378773293 00378773493 00378773497 00490007500 00490007530 00490007560 00490007590 00781168131 33358036902 33358037002 45802012714 45802012765 45802020514 45802020565 45963053930 49999078330 51079052401 51079052420 51079052501 51079052520 51672409103 52152053830 52152053930 54569587300 54868350800 54868350801 54868350802 54868350900 54868350901 54868350902 54868350903 54868508900 54868508901 54868508902 54868508903 54868508904 54868508905 54868573800 54868574900 54868574901 54868580100 54868580101 54868588700 55045372903 55045381501 55111015313 55111015330 55111015413 55111015430 55111015611 55289055903 55289055905 55289055906 12/19/2013 HCPCS Description ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI ANTI-EMETI Earliest Start Date 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 08/29/2011 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 07/10/2012 07/10/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 Latest End Date 12/31/2078 12/31/2078 12/31/2078 07/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2011 12/31/2078 07/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 10/01/2008 10/01/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/31/2013 03/31/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 08/31/2013 12/31/2078 08/31/2013 12/31/2078 08/31/2011 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 00071084018 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 04/01/1997 Q0163 00071219517 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/18/2003 04/01/1998 Q0163 00071233317 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/17/2003 04/01/1997 Q0163 00113037926 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/14/2004 12/31/2078 Q0163 00113043162 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/14/2004 12/31/2078 Q0163 00113046262 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/14/2004 12/31/2078 Q0163 00113047962 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/14/2004 12/31/2078 Q0163 00113047978 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/14/2004 12/31/2078 Q0163 00121048905 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00121048910 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00121048920 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00182049210 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 07/31/2011 Q0163 00182113193 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/03/2002 07/07/2008 Q0163 00182200137 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 04/30/2011 Q0163 00182209116 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 01/31/2010 Q0163 00182209201 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 06/30/2012 Q0163 00182209216 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 03/31/2012 Q0163 00182616837 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 07/31/2011 Q0163 00182616840 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 09/30/2011 HCPCS NDC Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0162 Q0163 58016008400 58016008410 58016008430 58016008460 58016008490 58016082600 58016082630 58016082660 58016082690 60505038105 62756013001 62756013101 62756024064 62756035664 62756035666 63304045830 63304045930 65862018730 65862018830 66336026803 66336079303 68462010530 68462010630 68462015713 68462015811 68462015813 00071084013 Q0163 12/19/2013 HCPCS Description ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2012 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/01/1997 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 00185064801 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 00185064810 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00185064901 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00185064910 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00501243104 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/02/2006 12/31/2078 Q0163 00536077085 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00536077097 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00536359401 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00536359701 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00536377206 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00555005902 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 07/31/2014 Q0163 00555005905 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 07/31/2014 Q0163 00603024018 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 04/30/2009 Q0163 00603024118 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/05/2007 12/31/2078 Q0163 00603082354 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00603082358 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00603082381 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/25/2002 12/31/2078 Q0163 00603082394 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00603086054 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00603333721 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/16/2002 05/31/2009 Q0163 00603333732 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 05/31/2009 Q0163 00603333821 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/16/2002 09/30/2008 Q0163 00603333832 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 09/30/2008 Q0163 00603333921 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/24/2007 12/31/2078 Q0163 00603333932 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/05/2007 12/31/2078 Q0163 00603334021 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/03/2007 12/31/2078 Q0163 00603334032 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/03/2007 12/31/2078 Q0163 00677185601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/29/2003 05/31/2009 Q0163 00677185610 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/29/2003 05/31/2009 Q0163 00677185701 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/14/2003 09/30/2008 Q0163 00677185710 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/14/2003 10/31/2008 Q0163 00677185801 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/28/2003 09/30/2008 Q0163 00761091420 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 00904122800 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 00904122820 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904203524 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904203559 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904205661 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904427451 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904517416 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904530660 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904530661 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/12/2003 12/31/2078 Q0163 00904530680 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904530760 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904530780 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00904555159 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/13/2002 12/31/2078 Q0163 00927022124 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00927061634 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 00927061712 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135014901 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135014910 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135014924 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135014961 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2002 12/31/2078 Q0163 10135015101 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135015110 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135015124 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135015150 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135015152 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135015157 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135015601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2002 12/31/2078 Q0163 10135015610 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2002 12/31/2078 Q0163 10135015613 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10135016613 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10158004201 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2012 Q0163 10158004302 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2012 Q0163 10158004304 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2012 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 10158004306 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 10267083501 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10267083504 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10267083601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10267083604 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10892011265 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 10956075024 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/02/2004 12/31/2078 Q0163 10956075048 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/02/2004 12/31/2078 Q0163 10956075124 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/02/2004 12/31/2078 Q0163 10956075148 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/02/2004 12/31/2078 Q0163 11822052710 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/02/2006 12/31/2078 Q0163 11845089601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 12280006824 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/12/2005 12/31/2078 Q0163 12280006830 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/21/2005 12/31/2078 Q0163 12280018500 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/22/2005 12/31/2078 Q0163 12547017021 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 12547017031 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 12547017033 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 12547017055 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 12547017136 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 12547017137 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/17/2003 12/31/2078 Q0163 12547017238 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 12810037926 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 16590007820 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/01/2006 12/31/2078 Q0163 16590007920 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/01/2006 12/31/2078 Q0163 17714002001 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 17714002010 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 17714002101 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 17714002110 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 17714004201 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 17714004224 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 18837004330 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2007 12/31/2078 Q0163 18837021330 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/26/2006 12/31/2078 12/19/2013 01/01/2002 12/31/2012 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 18837021398 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 18837029930 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/01/2008 12/31/2078 Q0163 18864021103 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 19458507601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 19458507602 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 19458916302 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 20254020706 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 20254020710 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 20254020806 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 20254020810 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 21695030430 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/01/2007 12/31/2078 Q0163 21695030490 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/17/2007 12/31/2078 Q0163 21695050030 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2008 12/31/2078 Q0163 23490545501 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/30/2007 12/31/2078 Q0163 23490545700 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/30/2007 12/31/2078 Q0163 23490545701 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545702 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545703 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545704 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545705 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545901 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545902 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545903 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 23490545904 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/07/2007 12/31/2078 Q0163 24385037926 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 24385040673 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 24385043126 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/03/2009 12/31/2078 Q0163 24385046262 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 24385046278 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 24385047962 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 24385047978 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 30103032254 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 30103072254 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 12/19/2013 10/26/2006 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 33358011030 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 33358011120 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/10/2007 12/31/2078 Q0163 33358011130 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/10/2007 12/31/2078 Q0163 37205027062 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 37205027078 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 37205027762 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 37205027778 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 37205056526 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 37205056534 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 41280022059 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 43292055631 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 43292055705 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 43292055719 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 43292055765 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 43292055778 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 47682018232 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2007 12/31/2078 Q0163 47682018247 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 47682018264 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2007 12/31/2078 Q0163 47682084787 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2007 12/31/2078 Q0163 47682085887 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2007 12/31/2078 Q0163 49348004404 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/21/2011 Q0163 49348004410 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 10/27/2011 Q0163 49348004534 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 49348020537 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 49348028208 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 49348056404 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 10/27/2011 Q0163 49483006101 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 49483006110 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 49614014662 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/13/2003 12/31/2078 Q0163 49614037926 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2004 12/31/2078 Q0163 49999000300 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/12/2004 12/31/2078 Q0163 49999000306 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/11/2002 12/31/2078 Q0163 49999000315 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/11/2002 12/31/2078 12/19/2013 07/10/2007 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 49999000320 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 49999000321 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/15/2004 12/31/2078 Q0163 49999000324 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/08/2002 12/31/2078 Q0163 49999000330 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/11/2002 12/31/2078 Q0163 49999000340 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/08/2002 12/31/2078 Q0163 49999000360 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/02/2005 12/31/2078 Q0163 49999009104 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/07/2003 12/31/2078 Q0163 49999009115 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/26/2003 12/31/2078 Q0163 49999009120 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/03/2002 12/31/2078 Q0163 49999009130 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/07/2003 12/31/2078 Q0163 49999009160 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/07/2003 12/31/2078 Q0163 49999024704 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/07/2003 12/31/2078 Q0163 50332013208 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/01/2007 12/31/2078 Q0163 50486061616 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/04/2002 12/31/2078 Q0163 50486061632 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/04/2002 12/31/2078 Q0163 50580084310 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/26/2004 12/31/2078 Q0163 50580084313 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/08/2004 12/31/2078 Q0163 50580084324 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 50580084325 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/08/2002 12/31/2078 Q0163 50580084348 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 50580084372 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 51079006601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 05/31/2013 Q0163 51079006619 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 09/30/2009 Q0163 51079006620 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 05/31/2013 Q0163 51079096701 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 51079096717 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 51079096719 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 11/30/2012 Q0163 51079096720 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 11/30/2012 Q0163 51655008824 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 51655008852 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 51655011324 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 51655011325 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 51655011327 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 12/19/2013 02/24/2005 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 51655011380 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 51655013354 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/22/2005 12/31/2078 Q0163 52297026867 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 06/15/2002 Q0163 52297037926 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2003 Q0163 52297046262 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2003 Q0163 52297052162 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2003 Q0163 52297094810 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2003 Q0163 52959004300 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/17/2003 12/31/2078 Q0163 52959004304 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959004310 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959004315 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959004320 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959004324 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/12/2003 12/31/2078 Q0163 52959004330 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959004350 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959004360 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959005306 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959005310 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959005312 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959005315 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959005320 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959005330 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959005352 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/24/2005 12/31/2078 Q0163 52959012303 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 52959012306 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 53100012822 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 53100012832 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 53100012851 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 53100012875 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569023900 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569023901 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569023902 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569023903 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 12/19/2013 06/22/2005 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 54569023908 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 54569024100 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569024102 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569024103 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569024105 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569350400 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569350401 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54569419700 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54838013540 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54838013570 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54838013580 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54838015440 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54838015470 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54838015480 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868002600 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868002601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868002604 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868002605 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868002606 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868002607 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 06/29/2006 12/31/2078 Q0163 54868105000 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868105001 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868105003 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868105004 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868105005 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 54868105006 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 54868122700 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/23/2006 12/31/2078 Q0163 54868122702 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/22/2002 12/31/2078 Q0163 55045112400 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/01/2004 12/31/2078 Q0163 55045112401 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112402 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112403 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112404 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 55045112405 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 55045112406 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112407 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112408 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2003 12/31/2078 Q0163 55045112409 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112500 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112501 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/01/2004 12/31/2078 Q0163 55045112502 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/01/2004 12/31/2078 Q0163 55045112503 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 12/06/2004 12/31/2078 Q0163 55045112504 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2003 12/31/2078 Q0163 55045112505 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/02/2004 12/31/2078 Q0163 55045112506 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2003 12/31/2078 Q0163 55045112508 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2003 12/31/2078 Q0163 55045112509 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 02/01/2004 12/31/2078 Q0163 55045125202 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2003 12/31/2078 Q0163 55045278106 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/01/2004 12/31/2078 Q0163 55289010001 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289010010 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289010015 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289010020 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289010030 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289010040 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/09/2002 12/31/2078 Q0163 55289047901 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289047910 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289047912 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/01/2006 12/31/2078 Q0163 55289047915 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289047920 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289047924 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55289047930 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55887088520 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55887088530 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/01/2004 12/31/2078 Q0163 55887097320 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55887097328 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/01/2004 12/31/2078 12/19/2013 01/01/2003 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 55887097330 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 55966011501 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 55966099805 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 57866359401 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 57866359402 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 57866359405 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 57866359406 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 57866376201 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 57866376202 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 57866376204 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2002 12/31/2078 Q0163 57866376205 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/22/2006 12/31/2078 Q0163 57896078101 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/01/2002 12/31/2078 Q0163 57896078201 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/01/2002 12/31/2078 Q0163 58016040800 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040806 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040809 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040810 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040812 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040814 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040815 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040820 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040821 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040824 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2007 12/31/2078 Q0163 58016040825 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2007 12/31/2078 Q0163 58016040828 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040830 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040840 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040860 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040900 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040910 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040912 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040915 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040920 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 12/19/2013 04/01/2004 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 58016040921 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 58016040924 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/26/2002 12/31/2078 Q0163 58016040930 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58016040940 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2007 12/31/2078 Q0163 58016040960 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/01/2006 12/31/2078 Q0163 58016040990 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 08/01/2006 12/31/2078 Q0163 58864016230 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 58864016256 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/01/2004 12/31/2078 Q0163 58864016330 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59390006535 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59390006546 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59390006547 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59618019933 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59618020006 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59741011904 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59741011908 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59741011916 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 59741011920 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 60242020201 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/06/2007 12/31/2078 Q0163 60242020210 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 07/06/2007 12/31/2078 Q0163 60432003304 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 05/31/2008 Q0163 60432003308 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 05/31/2008 Q0163 60432003316 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 09/30/2008 Q0163 60760033030 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63629134301 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2004 12/31/2078 Q0163 63629134302 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2004 12/31/2078 Q0163 63629134303 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2004 12/31/2078 Q0163 63629134304 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2004 12/31/2078 Q0163 63629134901 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2004 12/31/2078 Q0163 63629134902 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2004 12/31/2078 Q0163 63629134903 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2004 12/31/2078 Q0163 63868008701 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63868008724 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 12/19/2013 01/01/2007 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 63868050001 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 63868061132 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63868061232 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/01/2006 12/31/2078 Q0163 63868075124 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/15/2003 12/31/2078 Q0163 63868078924 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/01/2003 12/31/2078 Q0163 63868082354 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63868099524 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/12/2003 12/31/2078 Q0163 63874000501 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000502 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000506 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000509 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000510 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000512 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000514 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000515 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000520 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000521 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000524 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000525 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000528 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000530 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000540 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000545 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000560 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000590 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000601 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000602 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000607 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000610 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000612 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000614 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000615 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000620 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 63874000625 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 63874000628 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 63874000630 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 63874000660 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/10/2004 12/31/2078 Q0163 65162015610 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/01/2004 12/31/2078 Q0163 65162015611 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/01/2004 12/31/2078 Q0163 65162051610 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/01/2004 03/31/2011 Q0163 65162051611 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/01/2004 02/28/2011 Q0163 65162051810 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/01/2004 01/31/2011 Q0163 65162051811 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/01/2004 04/30/2011 Q0163 66267008015 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66267008020 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/05/2002 12/31/2078 Q0163 66267008030 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66267008060 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66267008115 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66267008120 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/05/2002 12/31/2078 Q0163 66267008130 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66267008160 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 09/04/2002 12/31/2078 Q0163 66267097704 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66336004506 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/22/2004 12/31/2078 Q0163 66336004515 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/22/2004 12/31/2078 Q0163 66336004520 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/01/2010 12/31/2078 Q0163 66336004530 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/23/2003 12/31/2078 Q0163 66336004560 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 11/23/2003 12/31/2078 Q0163 66336004590 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 04/01/2010 12/31/2078 Q0163 66336058915 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66336058920 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/22/2004 12/31/2078 Q0163 66336058930 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/22/2004 12/31/2078 Q0163 66336058960 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/22/2004 12/31/2078 Q0163 66375010702 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 66375010802 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 68115011600 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/17/2004 12/31/2078 Q0163 68115011610 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/17/2004 12/31/2078 12/19/2013 05/10/2004 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0163 68115011612 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE Q0163 68115011615 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/01/2003 12/31/2078 Q0163 68115011620 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/17/2004 12/31/2078 Q0163 68115011624 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/26/2004 12/31/2078 Q0163 68115011630 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/01/2003 12/31/2078 Q0163 68115011660 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/17/2004 12/31/2078 Q0163 68115011706 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 03/29/2004 12/31/2078 Q0163 68115011715 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/01/2003 12/31/2078 Q0163 68115011720 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/05/2004 12/31/2078 Q0163 68115011730 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 10/01/2003 12/31/2078 Q0163 68115097604 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/20/2004 12/31/2078 Q0163 68387054130 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 05/01/2006 12/31/2078 Q0163 74300000133 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 74300000610 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 74300000611 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0163 75137021215 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRE 01/01/2002 12/31/2078 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 00093964301 00182821089 00378510501 00555052102 00781502001 21695057130 23490651201 23490651202 33358029920 33358029930 49884054901 51079054101 51079054119 51079054120 51655009387 51991019601 54569035000 54569035005 54868472100 54868472101 54868472102 54868472103 55045169602 55289056810 55289056812 55289056830 55887039530 57866629901 57866629902 58016032600 58016032612 58016032630 58016032660 58016032690 01/01/2002 01/01/2002 01/01/2002 04/29/2004 01/01/2002 08/22/2008 02/07/2007 02/07/2007 07/10/2007 07/10/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/22/2005 10/23/2002 06/26/2002 01/01/2002 02/10/2003 04/08/2003 06/09/2005 06/04/2007 12/06/2004 07/01/2005 10/01/2002 11/15/2007 04/01/2004 04/15/2002 10/01/2003 03/01/2007 09/15/2003 03/01/2007 03/01/2007 03/01/2007 12/31/2078 10/11/2007 12/31/2078 03/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/31/2008 12/31/2078 12/31/2078 01/31/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP PRESCRIP 05/01/2005 12/31/2078 Page 1 of 1 HCPCS NDC Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0164 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 58864070201 58864070215 59746011306 59746011310 63629184101 66336043406 66336043410 66993080502 68115030010 00093965201 00172369160 00182821189 00378511001 00555052202 00555052204 00781502101 16590032710 21695057230 23490650903 33358030010 33358030020 33358030030 33358030060 35356032500 38779018004 38779018005 38779018008 49452605301 49452605302 49452605303 49452605305 49452605904 49884055001 51079054201 51079054220 51552007405 51552007409 51655029489 51927213400 51927348900 51991019701 52959039115 52959047602 52959047610 52959047615 52959047620 52959047624 52959047630 52959047660 54569035101 54569035500 54569035502 54868108200 54868108201 54868108202 54868108203 54868108204 54868108205 54868108206 54888108203 55045112602 55045112603 55045112604 55045112606 55045112607 12/19/2013 HCPCS Description PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 5 MG, ORAL, FDA APPROVED PRESCRIP 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI 10 MG, ORAL, FDA APPROVED PRESCRI Earliest Start Date 06/15/2006 03/01/2004 01/01/2002 01/01/2002 11/01/2004 10/22/2004 08/18/2005 02/14/2003 01/05/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/07/2002 07/11/2002 01/01/2002 04/01/2007 07/24/2007 11/30/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 08/01/2008 03/08/2002 01/01/2002 01/01/2002 02/13/2002 02/13/2002 02/13/2002 04/01/2005 02/13/2002 01/01/2002 01/01/2002 01/01/2002 09/01/2003 09/01/2003 06/22/2005 09/08/2003 09/08/2003 10/23/2002 01/01/2002 08/09/2005 01/01/2002 01/01/2002 01/01/2002 10/27/2004 11/22/2004 11/22/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/29/2004 06/03/2005 08/24/2007 02/10/2005 06/09/2005 04/16/2007 10/20/2004 04/01/2005 07/01/2003 01/01/2003 11/10/2005 07/01/2005 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2009 12/31/2078 12/31/2078 10/17/2007 09/22/2007 12/31/2078 12/31/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 00004024133 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0166 00093748512 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 01/02/2008 12/31/2078 Q0166 00093748520 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 01/02/2008 12/31/2078 Q0166 00378100394 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 01/30/2007 11/30/2012 Q0166 00555057651 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 03/17/2008 12/31/2078 Q0166 00555057693 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 03/17/2008 12/31/2078 Q0166 16714022130 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 05/15/2008 12/31/2020 Q0166 16714022132 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 05/15/2008 12/31/2020 Q0166 51079047201 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 03/03/2008 11/30/2012 HCPCS NDC Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0165 Q0166 55045112608 55289022404 55289022406 55289022412 55887061930 57866629801 58016070600 58016070602 58016070603 58016070608 58016070630 58016070660 58016070690 58864064442 59746011506 59746011510 62991112202 62991112204 63370019825 63370019835 63370019845 63629133501 63629133502 63629133503 63874049001 63874049006 63874049008 63874049010 63874049012 63874049015 63874049020 63874049028 63874049030 63874049060 66336092115 66336092160 66993081002 66993081005 68115029800 68115029804 68115029812 68115029815 68115029830 68115029860 68115029890 00004024126 Q0166 12/19/2013 HCPCS Description PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRI GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 07/01/2003 05/21/2002 03/07/2008 04/02/2008 04/01/2004 04/15/2002 09/23/2004 09/23/2004 09/23/2004 01/01/2007 09/23/2004 09/23/2004 09/23/2004 03/01/2004 01/01/2002 01/01/2002 01/01/2002 09/15/2003 12/19/2003 12/19/2003 12/19/2003 11/01/2004 11/01/2004 11/01/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 05/10/2004 12/03/2007 05/29/2008 02/14/2003 02/14/2003 07/27/2006 07/27/2006 05/11/2004 07/27/2006 07/27/2006 07/01/2005 07/27/2006 01/01/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 09/30/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0166 51079047205 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP Q0166 54868413900 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 06/03/2005 12/31/2078 Q0166 54868413901 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 06/28/2005 12/31/2078 Q0166 54868413902 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 09/07/2005 12/31/2078 Q0166 54868413903 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 10/14/2005 12/31/2078 Q0166 54868413904 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 09/22/2005 12/31/2078 Q0166 54868413905 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 01/05/2006 12/31/2078 Q0166 54868413906 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 06/07/2006 12/31/2078 Q0166 63717080130 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 03/03/2008 12/31/2078 Q0166 64720019802 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 12/29/2007 11/30/2011 Q0166 64720019898 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 12/29/2007 11/30/2011 Q0166 67253041712 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 05/15/2008 12/31/2078 Q0166 67253041722 GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIP 05/15/2008 12/31/2078 Q0167 Q0167 Q0167 Q0167 Q0167 Q0168 Q0168 Q0168 Q0168 Q0168 Q0168 Q0168 Q0168 Q0168 Q0168 Q0168 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0169 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 00051002121 54569578900 54868308400 54868308401 54868308402 00051002221 00051002321 54868318900 54868318901 54868318902 54868318903 58016095100 58016095130 58016095160 58016095190 68115069225 00115104001 00406204001 00603543721 10702000201 33358041830 49999090220 52959091430 54868072100 55289094802 63629159101 63629159102 63629159103 63629159104 68382004001 68382004010 00115104101 00115104103 00115104201 00406204101 00406204110 00406204201 00463615610 00591530701 00591530710 01/01/2002 04/26/2006 01/01/2002 02/11/2004 01/27/2006 08/14/2006 01/01/2002 06/07/2005 01/30/2006 02/07/2006 06/06/2006 04/01/2004 04/01/2004 04/01/2004 04/01/2004 03/29/2004 02/12/2008 09/12/2006 08/25/2006 05/10/2007 07/24/2007 01/11/2007 11/26/2007 01/01/2002 05/09/2006 11/01/2004 11/01/2004 11/01/2004 11/01/2004 12/01/2005 02/27/2007 02/12/2008 04/01/2008 05/20/2008 09/12/2006 07/15/2007 09/12/2006 01/01/2002 04/15/2002 04/15/2002 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETI PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRES PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC 03/03/2008 11/30/2012 Page 1 of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escription PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC Earliest Start Date 04/15/2002 05/12/2006 05/12/2006 08/25/2006 08/25/2006 08/25/2006 01/01/2002 01/01/2002 01/01/2002 05/06/2008 01/11/2008 01/21/2008 01/16/2007 01/16/2007 01/16/2007 04/01/2007 02/01/2006 06/01/2006 02/01/2006 02/01/2006 02/01/2006 08/01/2007 09/01/2006 09/01/2006 09/01/2006 09/01/2006 04/01/2007 01/15/2008 04/01/2007 04/01/2007 03/14/2008 02/07/2007 02/07/2007 02/07/2007 04/09/2007 11/30/2007 03/12/2008 03/12/2008 11/30/2007 07/10/2007 07/10/2007 07/10/2007 07/10/2007 04/15/2005 06/05/2002 05/07/2003 12/01/2003 10/15/2003 04/15/2005 02/10/2004 07/01/2003 06/06/2005 05/23/2005 03/01/2004 02/01/2007 03/14/2005 01/01/2002 06/22/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/07/2007 07/02/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 54569175408 54569175409 54569416800 54868132300 54868132301 54868132302 54868132304 54868132305 54868132306 54868132307 54868132308 54868186700 54868284400 54868284401 55045159600 55045159601 55045159602 55045159603 55045159604 55045159605 55045159606 55045159608 55045159609 55045164309 55289046415 55289046479 55289053104 55887067504 55887093610 55887093612 55887093615 55887093620 55887093625 55887093628 55887093630 55887093660 55887093690 57866021501 57866432803 57866437901 57866437902 57866437904 57866437906 57866437907 57866437908 58016042400 58016042402 58016042403 58016042410 58016042412 58016042415 58016042420 58016042430 58016042440 58016042448 58016042450 58016042460 58016042473 58016042489 58016042490 58016400801 58864076110 58864076130 58864076142 60432060804 12/19/2013 HCPCS Description PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE PROMETHAZINE HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, HYDROCHLORIDE, 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC PRESC Earliest Start Date 11/12/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 06/15/2005 09/21/2005 01/01/2002 01/01/2002 04/21/2008 12/06/2004 12/06/2004 08/09/2004 01/01/2003 02/09/2003 01/01/2003 01/01/2003 01/01/2004 12/06/2004 01/01/2003 12/01/2003 02/01/2005 02/26/2008 04/01/2004 07/01/2003 07/01/2003 04/01/2004 07/01/2003 01/01/2006 07/01/2003 07/01/2003 01/01/2005 01/01/2005 02/01/2004 10/01/2003 11/01/2005 04/15/2002 04/15/2002 01/02/2006 01/02/2006 04/11/2006 01/01/2002 09/15/2003 09/15/2003 03/26/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2002 07/13/2003 09/15/2003 09/15/2003 09/15/2003 01/01/2002 08/01/2004 05/01/2004 08/01/2004 01/01/2002 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 35356009890 CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRES 02/29/2008 12/31/2078 Q0172 54868230200 CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRES 01/01/2002 12/31/2078 Q0172 54868230202 CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRES 01/01/2002 12/31/2078 Q0172 54868234700 CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRES 01/01/2002 12/31/2078 Q0172 54868246400 CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRES 01/01/2002 12/31/2078 Q0172 54868246402 CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRES 08/08/2007 12/31/2078 Q0173 16590024010 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 02/01/2006 12/31/2078 Q0173 16590024020 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 02/01/2006 12/31/2078 Q0173 20254001801 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 20254001803 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 33358035210 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 07/10/2007 12/31/2078 HCPCS NDC Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0170 Q0171 60432060816 60760083020 63629174201 63629174202 63629174203 63629174204 63629187001 63629187002 63739021310 63739021315 63874037001 63874037008 63874037010 63874037012 63874037015 63874037020 63874037024 63874037030 63874037040 63874037060 63874071212 66336008510 66336008512 66336008520 66336008525 66336008530 66336008560 68084015601 68115030200 68115030204 68115030210 68115030220 68115030230 68115030260 68115030290 68115059804 68382004101 68382004110 68387053612 68387053630 68387053660 68387053690 54868268401 Q0172 12/19/2013 HCPCS Description PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESC CHLORPROMAZINE HYDROCHLORIDE, 10 MG, ORAL, FDA APPROVED PRE 01/01/2002 06/01/2005 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 11/01/2004 02/27/2007 03/01/2006 05/07/2004 05/07/2004 05/07/2004 05/07/2004 05/07/2004 05/07/2004 05/07/2004 05/07/2004 05/07/2004 03/02/2006 01/01/2002 10/22/2004 10/22/2004 05/29/2008 05/29/2008 10/22/2004 05/29/2008 09/08/2006 07/27/2006 07/27/2006 10/26/2004 06/25/2004 10/01/2003 11/10/2004 07/27/2006 10/26/2004 12/01/2005 02/27/2007 03/08/2006 05/01/2006 05/04/2007 05/01/2006 02/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 01/01/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0173 33358035220 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED Q0173 51655052353 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 51991062501 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 52152016602 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 52152018502 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 08/22/2003 12/31/2078 Q0173 52959047910 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 52959047912 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 52959047920 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 52959047930 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 52959081710 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 10/04/2005 12/31/2078 Q0173 53489037601 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 08/29/2003 12/31/2078 Q0173 54569558900 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 08/26/2004 12/31/2078 Q0173 54569558901 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 09/02/2005 12/31/2078 Q0173 54868518100 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 11/18/2004 12/31/2078 Q0173 54868574100 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/05/2007 12/31/2078 Q0173 55045162803 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2003 12/31/2078 Q0173 55045320303 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 05/01/2005 12/31/2078 Q0173 55289021920 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 55289042817 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 55289095306 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 05/09/2006 12/31/2078 Q0173 55887008106 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 04/01/2007 12/31/2078 Q0173 58016097300 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097302 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 09/15/2003 12/31/2078 Q0173 58016097303 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 09/15/2003 12/31/2078 Q0173 58016097308 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097310 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 09/15/2003 12/31/2078 Q0173 58016097312 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097315 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097320 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097324 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097330 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097350 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 58016097360 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 09/15/2003 12/31/2078 12/19/2013 07/10/2007 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0173 58016097373 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED Q0173 58016097389 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 09/15/2003 12/31/2078 Q0173 58016097390 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 09/15/2003 12/31/2078 Q0173 61570007901 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 02/13/2002 12/31/2078 Q0173 66267020810 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 66267020820 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 01/01/2002 12/31/2078 Q0173 66336062910 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 04/01/2010 12/31/2078 Q0173 68115033920 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 10/01/2003 12/31/2078 Q0173 68115058800 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED 06/25/2004 12/31/2078 Q0174 Q0174 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0175 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 Q0176 54868196300 54868196301 00172366760 00172366860 00490009100 00490009130 00490009160 00490009190 00603509021 00603509028 00603509121 00603509128 00781104601 00781104610 00781104613 00781104701 00781104710 00781104713 12280027630 12280027660 12280027690 21695041460 54868268600 57866413201 57866413202 57866413203 60429015360 00172366960 00172367060 00603509221 00603509228 00603509321 00781104801 00781104810 00781104813 00781104901 00781104913 12280027730 12280027760 12280027790 21695041560 35356009660 54868268701 54868268702 57866413301 57866413302 57866413303 60429015460 02/11/2003 02/11/2003 01/01/2002 01/01/2002 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/21/2006 03/21/2006 03/21/2006 04/01/2007 01/01/2002 04/15/2002 04/15/2002 04/15/2002 10/22/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 03/21/2006 03/21/2006 03/21/2006 06/27/2007 02/29/2008 01/01/2002 06/12/2007 04/15/2002 04/15/2002 04/15/2002 10/22/2002 12/31/2078 12/31/2078 11/30/2008 10/30/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2013 11/30/2013 12/31/2013 10/31/2013 12/31/2078 09/30/2005 12/31/2078 12/31/2078 10/31/2005 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2013 06/30/2013 12/31/2013 12/31/2078 11/30/2005 12/31/2078 12/31/2078 01/31/2004 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/19/2013 THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIP THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIP PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EME PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMET 09/15/2003 12/31/2078 Page 1 of 1 HCPCS NDC Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 00069541066 00069544093 00069544097 00185061301 00185061305 00555032302 00555032304 00591080001 00591080005 10544032830 12280020504 16590035709 16590035712 16590035720 16590035730 21695057320 21695057330 23490573301 23490573302 33358018220 33358018230 51079007701 51079007720 51655053352 52959043310 52959043315 52959043320 52959043330 52959043340 52959043360 54569235305 54868016901 54868289200 54868289202 54868289203 54868289204 55045219502 55045219504 55045219505 55045219506 55045219507 55045219508 55045219509 55289022610 55289022615 55887042230 55887042260 57866389301 57866389302 57866389303 58016025900 58016025902 58016025910 58016025920 58016025930 58016025950 58016025960 58016025990 62927062104 62927062116 63629153301 63629153302 63629185601 63629185602 63874044202 12/19/2013 HCPCS Description HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION Earliest Start Date 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/18/2006 09/18/2006 01/01/2008 06/29/2005 05/01/2006 05/01/2006 05/01/2006 05/01/2006 08/14/2008 08/14/2008 02/07/2007 02/07/2007 07/10/2007 07/10/2007 11/26/2007 01/01/2002 06/22/2005 06/06/2002 02/28/2002 12/27/2004 10/17/2002 01/01/2002 12/27/2004 01/01/2002 01/01/2002 01/01/2002 01/01/2002 09/19/2005 10/11/2005 12/06/2004 07/01/2004 03/24/2003 12/06/2004 03/01/2004 02/01/2004 12/06/2004 01/01/2002 03/06/2008 04/01/2004 03/23/2007 04/15/2002 04/15/2002 04/15/2002 01/01/2002 01/01/2007 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2007 01/01/2002 01/01/2002 11/01/2004 11/01/2004 11/01/2004 11/01/2004 05/11/2004 Latest End Date 12/31/2078 12/01/2009 03/01/2008 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0177 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 63874044203 63874044204 63874044205 63874044209 63874044210 63874044214 63874044215 63874044220 63874044225 63874044228 63874044230 63874044240 63874044245 63874044260 63874044290 66336020820 66336020830 68115017700 68115017730 68115017760 00069542066 00185061501 00185061505 00555030202 00555030204 00555032402 00591080101 00591080105 38779022804 38779022805 49452365901 49452365902 49999003612 49999003660 51079007801 51079007820 51552097904 51927231600 52959083306 52959083320 54569257101 54868185400 54868185401 54868185403 54868185404 54868410900 55045166100 55045166101 55045166102 55045166103 55045166106 55045166108 55045166109 55289035410 57866389401 57866389402 57866389403 58016046410 58016046415 58016046420 58016046430 63874075701 63874075704 63874075710 63874075715 12/19/2013 HCPCS Description HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE HYDROXYZINE PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, PAMOATE, 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, MG, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, ORAL, FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA FDA APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED APPROVED PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION PRESCRIPTION Earliest Start Date 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 05/11/2004 10/22/2004 10/22/2004 05/05/2004 03/17/2004 10/01/2003 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/10/2002 01/01/2002 10/15/2004 07/01/2002 11/26/2007 01/01/2002 09/01/2003 09/08/2003 10/14/2005 10/14/2005 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 12/06/2004 12/06/2004 12/06/2004 09/01/2004 09/01/2004 06/01/2003 12/06/2004 10/01/2002 04/15/2002 04/15/2002 04/15/2002 01/01/2002 01/01/2002 01/01/2002 01/01/2002 01/15/2006 01/15/2006 01/15/2006 01/15/2006 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 00093730165 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/03/2007 01/31/2013 Q0179 00093730203 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/03/2007 11/30/2012 Q0179 00093730265 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/03/2007 11/30/2012 Q0179 00143242330 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 02/26/2008 12/31/2078 Q0179 00173044600 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 00173044602 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 11/30/2013 Q0179 00173044604 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 00173044700 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 00173044702 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 07/31/2013 Q0179 00173044704 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 00173048900 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 00173056900 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 00173057000 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 00173057004 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 08/31/2011 Q0179 00378031553 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 07/31/2011 Q0179 00378031593 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 12/31/2078 Q0179 00378034453 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 07/31/2011 Q0179 00378034493 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 12/31/2078 Q0179 00378773293 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 00378773493 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 00378773497 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 00490007500 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2007 12/31/2078 Q0179 00490007530 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2007 12/31/2078 Q0179 00490007560 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2007 12/31/2078 Q0179 00490007590 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2007 12/31/2078 Q0179 00781168131 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/13/2009 12/31/2078 Q0179 00781523864 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL 12/29/2008 12/31/2078 HCPCS NDC Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0178 Q0179 63874075720 63874075721 63874075724 63874075728 63874075730 63874075760 63874075790 68115017820 68387046830 68387046930 00093723656 Q0179 12/19/2013 HCPCS Description HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/15/2006 01/05/2004 03/01/2007 03/01/2007 08/01/2007 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0179 00781525713 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP Q0179 00781525731 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/27/2006 01/31/2013 Q0179 00781525733 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/27/2006 03/31/2011 Q0179 00781525813 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/27/2006 09/30/2011 Q0179 00781525831 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/27/2006 02/28/2013 Q0179 00781525833 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/27/2006 08/31/2011 Q0179 00781526564 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 03/31/2011 Q0179 00781526664 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 01/31/2010 Q0179 00781526680 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 02/28/2011 Q0179 18837018440 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 09/01/2006 12/31/2078 Q0179 33358036902 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/10/2007 12/31/2078 Q0179 33358037002 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/10/2007 12/31/2078 Q0179 45802012714 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 10/01/2008 Q0179 45802012765 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 10/01/2008 Q0179 45802020514 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 45802020565 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 49999078330 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/11/2006 12/31/2078 Q0179 50111081942 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 11/27/2006 10/31/2012 Q0179 50111094543 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 12/31/2078 Q0179 50111094643 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 12/31/2078 Q0179 50111094669 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 12/31/2078 Q0179 51079052401 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/09/2007 12/31/2078 Q0179 51079052420 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/09/2007 12/31/2078 Q0179 51079052501 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/09/2007 12/31/2078 Q0179 51079052520 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/09/2007 12/31/2078 Q0179 51672409103 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 09/19/2008 12/31/2078 Q0179 52152053830 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 03/31/2013 Q0179 52152053930 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 03/31/2013 Q0179 54569487201 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/07/2005 12/31/2078 Q0179 54569587300 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/12/2007 12/31/2078 Q0179 54868350800 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 54868350801 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/01/2002 12/31/2078 Q0179 54868350802 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/20/2003 12/31/2078 12/19/2013 12/27/2006 07/31/2011 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0179 54868350900 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP Q0179 54868350901 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/28/2005 12/31/2078 Q0179 54868350902 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/07/2005 12/31/2078 Q0179 54868350903 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/19/2005 12/31/2078 Q0179 54868508900 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/09/2004 12/31/2078 Q0179 54868508901 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/29/2005 12/31/2078 Q0179 54868508902 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 09/28/2005 12/31/2078 Q0179 54868508903 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 09/22/2005 12/31/2078 Q0179 54868508904 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/20/2005 12/31/2078 Q0179 54868508905 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 08/25/2006 12/31/2078 Q0179 54868573800 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/29/2006 12/31/2078 Q0179 54868574900 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/16/2007 12/31/2078 Q0179 54868574901 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/18/2007 12/31/2078 Q0179 54868580100 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/30/2007 12/31/2078 Q0179 54868580101 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/25/2007 12/31/2078 Q0179 54868588700 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 05/12/2008 12/31/2078 Q0179 55045372903 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 02/01/2007 12/31/2078 Q0179 55045381501 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 07/26/2007 12/31/2078 Q0179 55111015313 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 08/31/2013 Q0179 55111015330 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 12/31/2078 Q0179 55111015413 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 08/31/2013 Q0179 55111015430 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 12/31/2078 Q0179 55111015611 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 12/26/2006 08/31/2011 Q0179 55289055903 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 04/25/2008 12/31/2078 Q0179 55289055905 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/03/2008 12/31/2078 Q0179 55289055906 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 04/25/2008 12/31/2078 Q0179 55887007803 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 04/01/2007 12/31/2078 Q0179 58016008400 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 02/01/2006 12/31/2078 Q0179 58016008410 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 02/01/2006 12/31/2078 Q0179 58016008430 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 02/01/2006 12/31/2078 Q0179 58016008460 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 02/01/2006 12/31/2078 Q0179 58016008490 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 02/01/2006 12/31/2078 Q0179 58016082600 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/15/2004 12/31/2078 12/19/2013 01/01/2002 12/31/2078 Page 1 of 1 HCPCS NDC HCPCS Description Earliest Start Date Latest End Date Q0179 58016082630 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP Q0179 58016082660 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/15/2004 12/31/2078 Q0179 58016082690 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/15/2004 12/31/2078 Q0179 58177036322 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 10/31/2010 Q0179 58177036422 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 03/31/2010 Q0179 58177036456 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 03/31/2010 Q0179 60505038105 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 03/10/2008 12/31/2078 Q0179 62756013001 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 62756013101 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 62756024064 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 62756035664 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 62756035666 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 63304045830 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 63304045930 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 65862018703 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/31/2007 12/31/2078 Q0179 65862018705 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/31/2007 12/31/2078 Q0179 65862018730 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/31/2007 12/31/2078 Q0179 65862018803 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/31/2007 12/31/2078 Q0179 65862018805 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/31/2007 12/31/2078 Q0179 65862018830 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 10/31/2007 12/31/2078 Q0179 66336026803 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 03/17/2008 12/31/2078 Q0179 66336079303 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 03/17/2008 12/31/2078 Q0179 68115080230 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 01/20/2004 12/31/2078 Q0179 68462010530 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 68462010630 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/25/2007 12/31/2078 Q0179 68462015713 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 12/31/2078 Q0179 68462015811 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 12/31/2078 Q0179 68462015813 ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIP 06/27/2007 12/31/2078 Q0180 Q0180 Q0180 Q0180 Q0180 Q0180 Q0181 Q0515 Q2004 Q2009 00088120205 00088120243 00088120305 00088120343 54868413800 54868413801 00187024701 44087405001 00327001105 00071400705 01/01/2002 01/01/2002 01/01/2002 01/01/2002 02/10/2005 09/22/2005 07/10/2006 01/01/2006 01/01/2002 01/01/2002 12/31/2078 08/31/2011 12/31/2078 10/31/2012 12/31/2078 12/31/2078 12/31/2078 10/01/1995 12/31/2078 09/30/2010 12/19/2013 DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTIO DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTIO DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTIO DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTIO DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTIO DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTIO UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI INJECTION, SERMORELIN ACETATE, 1 MICROGRAM IRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, FOR EX INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT 01/15/2004 12/31/2078 Page 1 of 1 HCPCS NDC Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2009 Q2017 Q2017 Q2042 Q2044 Q2044 Q3026 Q3026 Q3026 Q4074 Q4079 Q4080 Q4080 Q4080 Q4080 Q4080 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4081 Q4083 Q4083 Q4083 Q4083 Q4083 Q4083 Q4084 Q4084 Q4084 Q4084 00071400810 00409485702 00409485710 10019026301 10019026303 10139002521 10139002522 55390017510 55390017610 63323040302 63323040310 64679072901 64679073001 00015307519 00015307597 64011024301 49401010101 49401010201 44087002203 44087004403 44087882201 10148010101 59075073015 10148010100 10148010101 10148010130 10148010200 10148010230 54868252300 54868252301 55513012601 55513012610 55513014401 55513014410 55513014801 55513014810 55513026701 55513026710 55513028301 55513028310 55513047801 55513047810 55513082301 55513082310 59676030201 59676030202 59676030301 59676030302 59676030401 59676030402 59676031001 59676031002 59676031204 59676032004 59676034001 08024072412 08024072420 08363776101 08363776501 18837026502 21695037402 21695031303 35356003401 35356003403 54868421900 12/19/2013 HCPCS Description INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG INJECTION, FOSPHENYTOIN, 50 MG INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT INJECTION, TENIPOSIDE, 50 MG INJECTION, TENIPOSIDE, 50 MG HYDROXYPROGESTERONE CAPROATE, PER 1MG BELIMUMAB PER 10MG INJECTION, BELIMUMAB, 10 MG INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, N INJECTION, NATALIZUMAB, 1 MG ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, N ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, N ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, N ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, N ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, N INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS INJECTION, EPOETIN ALFA, (DIALYSIS), 100 UNITS HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTI HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC Earliest Start Date 01/01/2002 08/05/2007 08/05/2007 08/06/2007 08/06/2007 08/08/2007 08/08/2007 08/06/2007 08/06/2007 08/16/2007 08/16/2007 07/25/2007 07/25/2007 01/01/2002 01/01/2002 02/04/2011 07/01/2011 01/01/2011 01/01/2003 01/01/2003 02/14/2005 01/01/2010 01/01/2005 07/01/2005 07/01/2005 07/01/2005 12/08/2005 12/08/2005 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2006 01/01/2007 01/01/2007 01/01/2007 01/01/2007 06/01/2007 02/01/2007 02/01/2007 10/19/2007 10/19/2007 01/01/2007 Latest End Date 02/28/2010 12/31/2078 12/31/2078 06/28/2009 06/28/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/14/2014 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 04/30/2008 10/31/2016 12/31/2078 04/30/2008 12/31/2078 11/30/2010 11/30/2010 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 07/31/2010 07/31/2010 12/31/2078 07/01/2013 12/31/2078 09/01/2013 12/31/2078 09/01/2013 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 HCPCS NDC Q4084 Q4084 Q4084 Q4085 Q4086 Q4087 Q4087 Q4087 Q4087 Q4088 Q4088 Q4088 Q4088 Q4088 Q4089 Q4089 Q4090 Q4090 Q4091 Q4091 Q4091 Q4091 Q4091 Q4091 Q4091 Q4091 Q4091 Q4092 Q4092 Q4092 Q4092 Q4092 Q4094 Q4094 Q4094 Q4094 Q4095 Q4096 Q4096 Q4096 Q4096 Q4096 Q4096 Q4097 Q4097 Q4097 Q4098 Q4098 Q4099 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 Q4100 58468009001 66267092103 68115053503 55566410001 59676036001 68209084301 68209084302 68209084303 68209084304 00944270002 00944270003 00944270004 00944270005 00944270006 44206030001 44206030010 60492005101 60492005201 61953000301 61953000302 61953000303 61953000304 61953000401 61953000402 61953000403 61953000404 61953000405 13533064512 13533064515 13533064520 13533064524 13533064571 00085180601 00172640544 00172640549 50383074225 00078043561 68516460001 68516460002 68516460101 68516460201 68516460302 68516460402 44206043605 44206043710 44206043820 54868431900 54868471500 49502060561 08533601002 08533601004 08533601005 08533601006 08533601007 08533601008 08533601009 08533601010 08533601012 08533601013 08533601014 08533602002 08533602003 08533602005 08533603001 08533603002 12/19/2013 HCPCS Description HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJEC HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJE HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJ INJECTION, IMMUNE GLOBULIN (OCTAGAM), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (OCTAGAM), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (OCTAGAM), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (OCTAGAM), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (GAMMAGARD LIQUID), INTRAVENOUS, INJECTION, IMMUNE GLOBULIN (GAMMAGARD LIQUID), INTRAVENOUS, INJECTION, IMMUNE GLOBULIN (GAMMAGARD LIQUID), INTRAVENOUS, INJECTION, IMMUNE GLOBULIN (GAMMAGARD LIQUID), INTRAVENOUS, INJECTION, IMMUNE GLOBULIN (GAMMAGARD LIQUID), INTRAVENOUS, INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC®) INTR INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC®) INTR INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUS INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUS INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LY INJECTION, IMMUNE GLOBULIN (GAMUNEX), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (GAMUNEX), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (GAMUNEX), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (GAMUNEX), INTRAVENOUS, NON-LYOPH INJECTION, IMMUNE GLOBULIN (GAMUNEX), INTRAVENOUS, NON-LYOPH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INH INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOP INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOP INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOP INJECTION, IRON DEXTRAN, 50 MG INJECTION, IRON DEXTRAN, 50 MG PERFOROMIST, 20 MCG/2 ML SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED Earliest Start Date 01/01/2007 01/01/2007 01/01/2007 01/01/2007 01/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 07/01/2007 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 04/01/2008 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 Latest End Date 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 03/24/2013 04/19/2013 06/26/2014 10/17/2013 10/22/2013 09/30/2008 10/31/2009 10/31/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1 Earliest Start Date Latest End Date 08478400405 SKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD 01/01/2009 12/31/2078 Q4104 08478400406 SKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD 01/01/2009 12/31/2078 Q4104 08478400408 SKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD 01/01/2009 12/31/2078 Q4105 Q4105 Q4105 Q4105 Q4106 Q4107 Q4107 Q4107 Q4107 Q4107 Q4107 Q4107 Q4107 Q4108 Q4108 Q4108 Q4108 Q4109 Q4109 Q4109 Q4109 Q4110 Q4110 Q4110 Q4110 Q9967 08478800402 08478800405 08478800406 08478800408 08541000101 08121860047 08121860055 08121860204 08121860404 08121860407 08121860505 08121860510 08121860530 08478401402 08478401405 08478401406 08478401408 08533649501 08533649503 08533649504 08533649506 08533607009 08533607440 08533607812 08533607880 00407141361 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2009 01/01/2011 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 12/31/2078 S0080 S0180 63323011310 INJECTION, PENTAMIDINE ISETHIONATE, 300 MG 00052027201 ETONOGESTREL 68MG IMPLANT 10/01/1999 01/01/2007 12/31/2078 12/31/2078 HCPCS NDC Q4100 Q4100 Q4101 Q4104 08533603003 30170000001 09978000199 08478400402 Q4104 12/19/2013 HCPCS Description SKIN SKIN SKIN SKIN SUBSTITUTE, SUBSTITUTE, SUBSTITUTE, SUBSTITUTE, NOT OTHERWISE SPECIFIED NOT OTHERWISE SPECIFIED APLIGRAF, PER SQUARE CENTIMETER INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), SKIN SUBSTITUTE, DERMAGRAFT, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETER SKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETER SKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETER SKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETER SKIN SUBSTITUTE, PRIMATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, PRIMATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, PRIMATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, PRIMATRIX, PER SQUARE CENTIMETER LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTR 01/01/2009 01/01/2009 01/01/2009 01/01/2009 12/31/2078 12/31/2078 12/31/2078 12/31/2078 Page 1 of 1
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