updated 11.4.14 x-over ndc hcpcs hcpcs description ndc ... ndc... · 4/14/2011  · updated 11.4.14...

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Updated 11.4.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only Fee Schedule 00003-2187-10 J0129 INJECTION, ABCIXIMAB, 10MG ORENCIA 250 MG VIAL 9/1/2010 99/99/9999 E01 00002-7140-01 J0130 INJECTION ABCIXIMAB, 10MG REOPRO 2 MG/ML VIAL 9/1/2010 99/99/9999 E01 51552-0671-01 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E01 51552-0671-02 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E01 51552-0671-03 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E01 51552-0671-04 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E01 51552-0671-05 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E01 51552-0671-06 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E01 55390-0612-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 2/28/2015 E01 55390-0613-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 1 GM VIAL 9/1/2010 3/31/2013 E01 63323-0105-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E01 63323-0325-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 500 MG/10 ML VIAL 9/1/2010 99/99/9999 E01 63323-0325-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 1,000 MG/20 ML VIAL 9/1/2010 99/99/9999 E01 00074-3799-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML SYRINGE 9/1/2010 99/99/9999 E01 00074-4339-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML PEN 9/1/2010 99/99/9999 E01 00074-4339-06 J0135 INJECTION (HUMIRA) HUMIRA CROHN'S STARTER PACK 9/1/2010 99/99/9999 E01 00469-8234-12 J0150 INJECTION, ADENOSINE ADENOCARD 6 MG/2 ML SYRINGE 9/1/2010 99/99/9999 E01 00469-8234-14 J0150 INJECTION, ADENOSINE ADENOCARD 12 MG/4 ML SYRINGE 9/1/2010 99/99/9999 E01 00703-8771-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 9/30/2011 E01 00703-8773-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 9/30/2011 E01 10019-0063-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 3/31/2013 E01 10019-0063-08 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML SYRINGE 9/1/2010 3/31/2011 E01 55390-0067-10 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 3/31/2014 E01 55390-0068-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 3/31/2014 E01 63323-0651-02 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 99/99/9999 E01 63323-0651-04 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 99/99/9999 E01 00469-0871-20 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E01 00469-0871-30 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E01 00143-9984-90 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E01 00409-4901-18 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E01 00409-4921-34 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E01 00409-7241-01 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E01 00517-1071-25 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E01 00517-1130-05 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E01 00548-1016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E01 00548-2016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E01 00548-3316-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 1/31/2014 E01 00548-9061-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 7/31/2014 E01 66860-0021-02 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 12/31/2010 E01 58468-0040-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 35 MG VIAL 9/1/2010 99/99/9999 E01 58468-0041-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 5 MG VIAL 9/1/2010 99/99/9999 E01 58468-1060-01 J0205 INJECTION, ALGLUCERASE CEREDASE 80 UNITS/ML VIAL 9/1/2010 12/31/2012 E01 62756-0581-40 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 3/31/2014 E01 62756-0581-42 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 3/31/2014 E01 55390-0308-03 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 99/99/9999 E01 58178-0017-01 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 9/30/2013 E01 58178-0017-03 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 9/30/2013 E01 00517-8905-10 J0210 INJECTION, METHYLDOPATE HCI METHYLDOPATE 250 MG/5 ML VIAL 9/1/2010 99/99/9999 E01 58468-0150-01 J0220 INJECTION, ALGLUCOSIDASE ALFA MYOZYME 50 MG VIAL 9/1/2010 99/99/9999 E01 00053-7201-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ZEMAIRA 1,000 MG VIAL 9/1/2010 99/99/9999 E01 00944-2801-01 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 500 MG VIAL 9/1/2010 12/31/2010 E01 00944-2801-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 1,000 MG VIAL 9/1/2010 10/27/2010 E01 13533-0601-30 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 500 MG VIAL 9/1/2010 9/30/2011 E01 13533-0601-35 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 1,000 MG VIAL 9/1/2010 12/17/2012 E01 00009-3169-06 J0270 INJECTION, ALPROSTADIL PROSTIN VR PEDI 500 MCG/ML AMP 9/1/2010 99/99/9999 E01 00009-3701-05 J0270 INJECTION, ALPROSTADIL CAVERJECT 20 MCG VIAL 9/1/2010 99/99/9999 E01 00009-5181-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 10 MCG KIT 9/1/2010 99/99/9999 E01 00009-5182-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 20 MCG KIT 9/1/2010 99/99/9999 E01 00009-7686-04 J0270 INJECTION, ALPROSTADIL CAVERJECT 40 MCG VIAL 9/1/2010 99/99/9999 E01 00091-1110-16 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E01 00091-1110-20 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E01 00091-1120-16 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E01 00091-1120-20 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E01 00091-1140-16 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E01 00091-1140-20 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 6-PK KIT 9/1/2010 5/8/2012 E01 00703-1501-02 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 99/99/9999 E01 51552-0498-03 J0270 INJECTION, ALPROSTADIL ALPROSTADIL POWDER 9/1/2010 3/31/2011 E01 55390-0503-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 12/31/2010 E01 55390-0506-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 9/30/2011 E01 62541-0110-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E01 62541-0110-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E01

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Page 1: Updated 11.4.14 X-Over NDC HCPCS HCPCS Description NDC ... NDC... · 4/14/2011  · Updated 11.4.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only

Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule00003-2187-10 J0129 INJECTION, ABCIXIMAB, 10MG ORENCIA 250 MG VIAL 9/1/2010 99/99/9999 E0100002-7140-01 J0130 INJECTION ABCIXIMAB, 10MG REOPRO 2 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0671-01 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-02 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-03 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-04 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-05 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-06 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0155390-0612-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 2/28/2015 E0155390-0613-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 1 GM VIAL 9/1/2010 3/31/2013 E0163323-0105-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0325-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 500 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0325-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 1,000 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100074-3799-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML SYRINGE 9/1/2010 99/99/9999 E0100074-4339-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML PEN 9/1/2010 99/99/9999 E0100074-4339-06 J0135 INJECTION (HUMIRA) HUMIRA CROHN'S STARTER PACK 9/1/2010 99/99/9999 E0100469-8234-12 J0150 INJECTION, ADENOSINE ADENOCARD 6 MG/2 ML SYRINGE 9/1/2010 99/99/9999 E0100469-8234-14 J0150 INJECTION, ADENOSINE ADENOCARD 12 MG/4 ML SYRINGE 9/1/2010 99/99/9999 E0100703-8771-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 9/30/2011 E0100703-8773-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 9/30/2011 E0110019-0063-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 3/31/2013 E0110019-0063-08 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML SYRINGE 9/1/2010 3/31/2011 E0155390-0067-10 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 3/31/2014 E0155390-0068-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 3/31/2014 E0163323-0651-02 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0651-04 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 99/99/9999 E0100469-0871-20 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E0100469-0871-30 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E0100143-9984-90 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-4901-18 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-4921-34 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-7241-01 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-1071-25 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-1130-05 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100548-1016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-2016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-3316-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 1/31/2014 E0100548-9061-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 7/31/2014 E0166860-0021-02 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 12/31/2010 E0158468-0040-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 35 MG VIAL 9/1/2010 99/99/9999 E0158468-0041-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 5 MG VIAL 9/1/2010 99/99/9999 E0158468-1060-01 J0205 INJECTION, ALGLUCERASE CEREDASE 80 UNITS/ML VIAL 9/1/2010 12/31/2012 E0162756-0581-40 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 3/31/2014 E0162756-0581-42 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 3/31/2014 E0155390-0308-03 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 99/99/9999 E0158178-0017-01 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 9/30/2013 E0158178-0017-03 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 9/30/2013 E0100517-8905-10 J0210 INJECTION, METHYLDOPATE HCI METHYLDOPATE 250 MG/5 ML VIAL 9/1/2010 99/99/9999 E0158468-0150-01 J0220 INJECTION, ALGLUCOSIDASE ALFA MYOZYME 50 MG VIAL 9/1/2010 99/99/9999 E0100053-7201-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ZEMAIRA 1,000 MG VIAL 9/1/2010 99/99/9999 E0100944-2801-01 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 500 MG VIAL 9/1/2010 12/31/2010 E0100944-2801-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 1,000 MG VIAL 9/1/2010 10/27/2010 E0113533-0601-30 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 500 MG VIAL 9/1/2010 9/30/2011 E0113533-0601-35 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 1,000 MG VIAL 9/1/2010 12/17/2012 E0100009-3169-06 J0270 INJECTION, ALPROSTADIL PROSTIN VR PEDI 500 MCG/ML AMP 9/1/2010 99/99/9999 E0100009-3701-05 J0270 INJECTION, ALPROSTADIL CAVERJECT 20 MCG VIAL 9/1/2010 99/99/9999 E0100009-5181-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 10 MCG KIT 9/1/2010 99/99/9999 E0100009-5182-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 20 MCG KIT 9/1/2010 99/99/9999 E0100009-7686-04 J0270 INJECTION, ALPROSTADIL CAVERJECT 40 MCG VIAL 9/1/2010 99/99/9999 E0100091-1110-16 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1110-20 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E0100091-1120-16 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1120-20 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E0100091-1140-16 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1140-20 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 6-PK KIT 9/1/2010 5/8/2012 E0100703-1501-02 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 99/99/9999 E0151552-0498-03 J0270 INJECTION, ALPROSTADIL ALPROSTADIL POWDER 9/1/2010 3/31/2011 E0155390-0503-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 12/31/2010 E0155390-0506-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 9/30/2011 E0162541-0110-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E0162541-0110-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E01

Page 2: Updated 11.4.14 X-Over NDC HCPCS HCPCS Description NDC ... NDC... · 4/14/2011  · Updated 11.4.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only

Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

62541-0120-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 250 MCG URETHRAL SUPPOS 9/1/2010 12/31/2012 E0162541-0120-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 250 MCG URETHRAL SUPPOS 9/1/2010 12/31/2012 E0162541-0130-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOS 9/1/2010 7/31/2013 E0162541-0130-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOS 9/1/2010 7/31/2013 E0162541-0140-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 1,000 MCG URETHRAL SUPP 9/1/2010 7/31/2013 E0162541-0140-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 1,000 MCG URETHRAL SUPP 9/1/2010 7/31/2013 E0100409-1955-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 100 MG/2 ML 9/1/2010 9/30/2011 E0100409-1956-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 500 MG/2 ML 9/1/2010 11/1/2012 E0100409-1957-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 1,000 MG/4 ML 9/1/2010 9/30/2011 E0100703-9032-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100703-9040-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 1 GRAM/4 ML VIAL 9/1/2010 99/99/9999 E0155390-0223-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN (PF) 100 MG/2 ML 9/1/2010 12/31/2010 E0155390-0224-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 500 MG/2 ML 9/1/2010 12/31/2010 E0155390-0224-04 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 1,000 MG/4 ML 9/1/2010 12/31/2010 E0155390-0225-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN (PF) 100 MG/2 ML 9/1/2010 9/30/2011 E0155390-0226-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 9/1/2010 7/31/2015 E0155390-0226-04 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 1 GRAM/4 ML VIAL 9/1/2010 9/30/2013 E0100409-5921-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 99/99/9999 E0100409-5922-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 99/99/9999 E0100409-7385-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 9/30/2011 E0100409-7386-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 7/1/2011 E0100517-3810-25 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 12/31/2012 E0100517-3820-25 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 12/31/2012 E0151552-0313-05 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE ANHYDROUS PWD 9/1/2010 3/31/2011 E0151552-0313-06 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE ANHYDROUS POWDER 9/1/2010 3/31/2011 E0100409-4348-35 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML AMP 9/1/2010 99/99/9999 E0100548-3380-00 J0282 INJECTION,AMIODARONE AMIODARONE HCL 50 MG/ML SYRN 9/1/2010 3/31/2011 E0100703-1335-01 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 2/28/2011 E0155390-0057-01 J0282 INJECTION,AMIODARONE AMIODARONE 900 MG/18 ML VIAL 9/1/2010 9/30/2011 E0155390-0057-10 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML VIAL 9/1/2010 9/30/2011 E0155390-0105-01 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 9/30/2011 E0163323-0616-03 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML VIAL 9/1/2010 99/99/9999 E0163323-0616-09 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 99/99/9999 E0139822-1055-05 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B 50 MG VIAL 9/1/2010 99/99/9999 E0139822-1055-07 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B 50 MG VIAL 9/1/2010 1/31/2014 E0151552-0304-01 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-02 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-03 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-04 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-05 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-06 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-07 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-09 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0157665-0101-41 J0287 INJECTION, AMPHOTERICIN ABELCET 100 MG/20 ML VIAL 9/1/2010 99/99/9999 E0166435-0301-51 J0288 INJECTION AMPHOTERICIN B CHOLESTERYL SUL AMPHOTEC 50 MG VIAL 9/1/2010 99/99/9999 E0100469-3051-30 J0289 INJECT, AMPHOTERICIN B LIPOSOME AMBISOME 50 MG VIAL 9/1/2010 99/99/9999 E0100781-3400-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 9/1/2010 99/99/9999 E0100781-3402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 9/1/2010 99/99/9999 E0100781-3404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100781-3409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-3412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 9/1/2010 99/99/9999 E0100781-3413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 9/1/2010 99/99/9999 E0100781-9401-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 9/1/2010 99/99/9999 E0100781-9402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 9/1/2010 99/99/9999 E0100781-9404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100781-9407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-9408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100781-9409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 9/1/2010 99/99/9999 E0100781-9413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 9/1/2010 99/99/9999 E0163323-0387-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 9/1/2010 99/99/9999 E0163323-0388-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0389-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0399-23 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100049-0013-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 1.5 GM VIAL 9/1/2010 99/99/9999 E0100049-0014-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 3 GM VIAL 9/1/2010 99/99/9999 E0100049-0022-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 1.5 GM PIGGYBACK BOTTLE 9/1/2010 12/31/2013 E0100049-0023-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 3 GM PIGGYBACK BOTTLE 9/1/2010 12/31/2013 E0100049-0024-28 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 15 GM VIAL 9/1/2010 99/99/9999 E01

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00049-0031-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 1.5 GM ADD-VANTAGE VL 9/1/2010 6/30/2013 E0100049-0032-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 3 GM ADD-VANTAGE VIAL 9/1/2010 6/30/2013 E0100409-2687-15 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 99/99/9999 E0100409-2689-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100409-2689-11 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100409-2987-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULB 3 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-2987-13 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULB 3 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-2988-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100409-2998-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 99/99/9999 E0100781-3032-95 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100781-3033-95 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 99/99/9999 E0100781-3034-46 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 99/99/9999 E0110019-0630-02 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 10/31/2013 E0110019-0631-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 10/31/2013 E0110019-0631-31 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 10/31/2013 E0110019-0632-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 10/31/2013 E0110019-0633-02 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 7/31/2013 E0110019-0634-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 7/31/2013 E0110019-0635-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 2/28/2013 E0110019-0636-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 10/31/2013 E0110019-0637-02 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 10/31/2013 E0110019-0638-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 10/31/2013 E0163323-0368-20 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0163323-0369-20 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 99/99/9999 E0163323-0370-62 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 99/99/9999 E0163304-0303-10 J0300 INJECTION, AMOBARBITAL, UP TO 125 MG AMYTAL SODIUM 500 MG VIAL 9/1/2010 12/31/2012 E0100409-6629-02 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 200 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100409-6629-61 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 200 MG/10 ML VIAL 9/1/2010 9/30/2011 E0100409-6970-10 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 100 MG/ML VIAL 9/1/2010 8/1/2013 E0100781-3009-95 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T ANECTINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100049-1010-28 J0348 INJECTION, ANIDULAFUNGIN, 1 MG ERAXIS(ALCOHOL DIL) 50 MG VIAL 9/1/2010 9/1/2010 E0100517-0901-25 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0614-01 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0614-55 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0652-01 J0364 INJECTION, APOMORPHINE HYDR., 1 MG APOMORPHINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0652-02 J0364 INJECTION, APOMORPHINE HYDR., 1 MG APOMORPHINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0652-04 J0364 INJECTION, APOMORPHINE HYDR., 1 MG APOMORPHINE HCL POWDER 9/1/2010 3/31/2011 E0100026-8196-36 J0365 INJECTION, APROTONIN TRASYLOL 10,000 UNITS/ML VIAL 9/1/2010 3/31/2011 E0100026-8197-63 J0365 INJECTION, APROTONIN TRASYLOL 10,000 UNITS/ML VIAL 9/1/2010 3/31/2011 E0159148-0016-65 J0400 ARIPIPRAZOLE INJECTION ABILIFY 9.7 MG/1.3 ML VIAL 9/1/2010 99/99/9999 E0100069-3150-14 J0456 INJECTION, AZITHROMYCIN ZITHROMAX I.V. 500 MG VIAL 9/1/2010 5/31/2014 E0100069-3150-83 J0456 INJECTION, AZITHROMYCIN ZITHROMAX I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0100703-9089-01 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN 2.5 GM BULK VIAL 9/1/2010 11/30/2011 E0110019-0648-02 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 12/31/2011 E0150111-0794-78 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0398-10 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0398-12 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0100517-1010-25 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-6006-10 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 8 MG/20 ML VIAL 8/29/2012 99/99/9999 E0100409-4910-34 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 0.1 MG/ML ABBOJECT 9/1/2010 99/99/9999 E0111098-0526-03 J0470 INJECTION, DIMECAPROL, PER 100 MG BAL IN OIL 100 MG/ML AMPULE 9/1/2010 2/28/2014 E0151552-0613-02 J0475 INJECTION, BACLOFEN BACLOFEN POWDER 9/1/2010 3/31/2011 E0151552-0613-04 J0475 INJECTION, BACLOFEN BACLOFEN POWDER 9/1/2010 3/31/2011 E0151552-0613-05 J0475 INJECTION, BACLOFEN BACLOFEN POWDER 9/1/2010 3/31/2011 E0158281-0560-01 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0560-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0561-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/5 ML KIT 9/1/2010 99/99/9999 E0158281-0563-01 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0563-02 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0562-01 J0476 BACLOFEN LIORESAL IT 0.05 MG/1 ML AMP 9/1/2010 99/99/9999 E0100078-0331-84 J0480 INJECTION, BASILIXIMAB SIMULECT 20 MG VIAL 9/1/2010 99/99/9999 E0100078-0393-61 J0480 INJECTION, BASILIXIMAB SIMULECT 10 MG VIAL 9/1/2010 99/99/9999 E0151552-0741-04 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG DICYCLOMINE HCL POWDER 9/1/2010 3/31/2011 E0155390-0066-10 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG DICYCLOMINE 10 MG/ML VIAL 9/1/2010 9/30/2011 E0158914-0080-52 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG BENTYL 10 MG/ML AMPUL 9/1/2010 99/99/9999 E0151552-0952-01 J0515 INJECTION, BENZTROPINE BENZTROPINE MESYLATE POWDER 9/1/2010 3/31/2011 E0167386-0611-52 J0515 INJECTION, BENZTROPINE COGENTIN 2 MG/2 ML AMPULE 9/1/2010 11/30/2013 E0160793-0700-10 J0560 INJECTION, PENICILLIN G BENZATHINE, UP T BICILLIN L-A 600,000 UNIT/ML 9/1/2010 99/99/9999 E0160793-0701-10 J0560 INJECTION, PENICILLIN G BENZATHINE, UP T BICILLIN L-A 1,200,000 UNITS 9/1/2010 99/99/9999 E0160793-0702-10 J0560 INJECTION, PENICILLIN G BENZATHINE, UP T BICILLIN L-A 2,400,000 UNITS 9/1/2010 99/99/9999 E0115054-0530-06 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 300 UNIT VIAL 11/29/2010 3/31/2013 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

15054-0500-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 500 UNITS VIAL 9/1/2010 3/31/2013 E0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 9/1/2010 99/99/9999 E0100023-9232-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 100 UNITS VIAL 9/1/2010 99/99/9999 E0100023-9232-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 9/1/2010 12/31/2012 E0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 9/1/2010 99/99/9999 E0100023-3919-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 8/30/2011 99/99/9999 E0100023-3921-02 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 200 UNITS VIAL 9/1/2010 99/99/9999 E0115054-0500-01 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 500 UNITS VIAL 4/1/2013 99/99/9999 E0115054-0530-06 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 300 UNIT VIAL 4/1/2013 99/99/9999 E0110454-0710-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 2,500 UNIT/0.5 ML VIAL 9/1/2010 99/99/9999 E0110454-0711-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 5,000 UNITS/1 ML VIAL 9/1/2010 99/99/9999 E0110454-0712-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 10,000 UNITS/2 ML VIAL 9/1/2010 99/99/9999 E0100409-2012-32 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENORPHINE 0.3 MG/ML SYRN 9/1/2010 99/99/9999 E0112496-0757-01 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENEX 0.3 MG/ML AMPUL 9/1/2010 99/99/9999 E0155390-0100-10 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENORPHINE 0.3 MG/ML VIAL 9/1/2010 3/31/2014 E0167286-0053-08 J0594 INJECTION, BUSULFAN, 1 MG BUSULFEX 6 MG/ML AMPUL 9/1/2010 9/30/2013 E0167286-0054-08 J0594 INJECTION, BUSULFAN, 1 MG BUSULFEX 60 MG/10 ML VIAL 9/1/2010 9/30/2013 E0100409-1623-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1626-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1626-02 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0155390-0183-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0184-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0184-02 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0185-10 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 3/31/2014 E0160505-0658-00 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0160505-0659-00 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0160505-0660-00 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0161703-0317-45 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 9/30/2011 E0161703-0318-45 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 9/30/2011 E0163833-0825-02 J0598 INJECTION, C1 ESTERASE INHIBITOR, 10 UNI BERINERT 500 UNIT KIT 2/1/2013 99/99/9999 E0151552-0435-05 J0600 INJECTION, EDETATE CALCIUM DISODIUM, UP EDETATE CALCIUM DISODIUM POWD 9/1/2010 3/31/2011 E0100517-3900-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0100517-3910-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 12/31/2012 E0100517-3950-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-10 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-50 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-61 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-63 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 12/31/2011 E0100078-0149-23 J0630 INJECTION, CALCITONIN SALMON, UP TO 400 MIACALCIN 200 UNIT/ML VIAL 9/1/2010 99/99/9999 E0100074-8110-31 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCIJEX 1 MCG/ML AMPUL 9/1/2010 8/1/2012 E0100517-0132-25 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCITRIOL 1 MCG/ML AMPUL 9/1/2010 99/99/9999 E0100703-7311-04 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCITRIOL 1 MCG/ML VIAL 9/1/2010 9/30/2011 E0163323-0731-01 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCITRIOL 1 MCG/ML AMPUL 9/1/2010 99/99/9999 E0100006-3822-10 J0637 INJECTION, CASPOFUNGIN ACETATE, 5 MG CANCIDAS IV 50 MG VIAL 9/1/2010 99/99/9999 E0100006-3823-10 J0637 INJECTION, CASPOFUNGIN ACETATE, 5 MG CANCIDAS IV 70 MG VIAL 9/1/2010 99/99/9999 E0125021-0815-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 2/15/2013 99/99/9999 E0125021-0816-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 2/15/2013 99/99/9999 E0100703-5140-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 9/1/2010 99/99/9999 E0100703-5145-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 9/1/2010 99/99/9999 E0155390-0009-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 9/1/2010 6/30/2013 E0155390-0051-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 50 MG VIAL 9/1/2010 8/31/2013 E0155390-0052-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 9/1/2010 8/31/2014 E0155390-0053-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 9/1/2010 4/30/2014 E0155390-0054-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 9/1/2010 2/28/2015 E0155390-0818-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 9/1/2010 8/31/2014 E0155390-0824-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 9/1/2010 4/30/2014 E0155390-0825-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 9/1/2010 5/31/2013 E0155390-0826-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 9/1/2010 6/30/2013 E0163323-0711-00 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 500 MG VL 9/1/2010 99/99/9999 E0163323-0710-50 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 8/30/2011 99/99/9999 E0168152-0101-00 J0641 INJECTION, LEVOLEUCOVORIN CALCIUM FUSILEV I.V. 50 MG VIAL 9/1/2010 99/99/9999 E0100186-0410-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 1% VIAL 9/1/2010 12/31/2011 E0100186-0412-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 1% VIAL 9/1/2010 9/30/2011 E0100186-0418-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 1.5% VIAL 9/1/2010 8/31/2011 E0100186-0422-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 2% VIAL 9/1/2010 3/31/2012 E0100409-1036-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 9/1/2010 99/99/9999 E0100409-1038-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 9/1/2010 99/99/9999 E0100409-1041-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1.5% VIAL 9/1/2010 99/99/9999 E0100409-1067-20 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 9/1/2010 99/99/9999 E0100409-2047-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 9/1/2010 99/99/9999 E0125021-0100-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00143-9923-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100143-9924-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9983-91 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100264-3103-11 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM-D5W BAG 9/1/2010 99/99/9999 E0100338-3503-41 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM-D5W BAG 9/1/2010 99/99/9999 E0100409-2585-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM ADD-VAN VIAL 9/1/2010 99/99/9999 E0100781-3450-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3451-96 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3452-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9337-46 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9337-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 9/30/2014 E0110019-0610-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 12/31/2011 E0110019-0611-03 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0611-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 9/30/2013 E0110019-0612-05 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 12/31/2011 E0160505-0749-04 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0749-05 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0769-00 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0236-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0237-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0238-61 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0446-61 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 20 GM BULK VIAL 9/1/2010 3/30/2012 E0166860-0001-03 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 12/31/2010 E0166860-0002-03 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 12/31/2010 E0166860-0003-02 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 12/31/2010 E0100409-0805-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0151479-0054-20 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 1 GM ADD-VANTAGE VL 9/1/2010 8/30/2012 E0151479-0054-30 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 1 GRAM VIAL 9/1/2010 12/31/2010 E0151479-0055-10 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 2 GM ADD-VANTAGE VL 9/1/2010 11/30/2012 E0151479-0055-30 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 2 GRAM VIAL 9/1/2010 12/31/2010 E0160505-0681-00 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 2 GRAM VIAL 9/1/2010 99/99/9999 E0160505-0681-04 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 2 GRAM VIAL 9/1/2010 99/99/9999 E0160505-0834-00 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0834-04 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 1 GM VIAL 9/1/2010 99/99/9999 E0100264-3123-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM PIGGYBACK BAG 9/1/2010 99/99/9999 E0100264-3125-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM PIGGYBACK BAG 9/1/2010 99/99/9999 E0160505-0759-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0760-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM VIAL 9/1/2010 99/99/9999 E0160505-0761-04 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0341-20 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM VIAL 9/1/2010 8/30/2012 E0163323-0342-20 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM VIAL 9/1/2010 8/30/2012 E0163323-0343-61 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 9/1/2010 99/99/9999 E0155390-0310-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2014 E0125021-0104-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2010 E0125021-0105-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0125021-0106-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0125021-0107-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100517-8711-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 12/31/2012 E0100517-8722-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 12/31/2012 E0100517-8725-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2012 E0100517-8750-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2012 E0168330-0005-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/1/2010 9/30/2011 E0155390-0309-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2014 E0155390-0311-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 12/31/2014 E0100069-4481-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2011 E0100069-4481-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2011 E0100069-4482-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 5/31/2012 E0100069-4482-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 5/31/2012 E0100703-0315-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 1/31/2013 E0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E0100703-0335-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 4/30/2013 E0100703-0346-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 1/31/2013 E0100703-0359-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 1/31/2013 E0100781-3208-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0168330-0006-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 9/1/2010 9/30/2011 E0100781-9328-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9856-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100143-9857-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9858-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100143-9859-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00004-1963-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 9/1/2010 99/99/9999 E0100004-1963-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 9/1/2010 99/99/9999 E0100004-1964-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 9/1/2010 99/99/9999 E0100004-1964-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 9/1/2010 99/99/9999 E0100264-3153-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM-D5W BAG 9/1/2010 99/99/9999 E0100264-3155-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM-D5W BAG 9/1/2010 99/99/9999 E0100338-5002-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/1/2010 99/99/9999 E0100338-5003-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 9/1/2010 99/99/9999 E0100409-7332-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100409-7333-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100409-7333-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100409-7334-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0100409-7335-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100409-7336-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-7336-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-7337-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100409-7338-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3206-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100781-9326-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 7/31/2015 E0110019-0098-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0110019-0098-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0110019-0685-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2011 E0110019-0685-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2013 E0110019-0686-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2011 E0110019-0686-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2013 E0110019-0687-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0687-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 9/30/2013 E0110019-0688-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0110019-0688-27 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0110019-0689-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0160505-0679-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0160505-0679-08 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/1/2010 99/99/9999 E0160505-0679-09 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 9/1/2010 99/99/9999 E0160505-0750-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0160505-0750-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0160505-0751-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0160505-0751-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0160505-0752-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0752-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0753-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0160505-0753-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0163323-0344-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0163323-0345-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0346-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0347-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0163323-0348-61 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0168180-0611-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0168180-0611-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0168180-0622-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0168180-0622-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0168180-0633-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0168180-0633-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0168180-0644-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0168180-0644-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0168330-0001-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2011 E0168330-0001-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2011 E0168330-0002-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E0168330-0002-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E0168330-0003-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 9/30/2011 E0168330-0003-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 9/30/2011 E0168330-0004-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 9/30/2011 E0168330-0004-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 9/30/2011 E0164679-0701-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0164679-0701-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0164679-0701-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2011 E0164679-0702-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0164679-0703-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0164679-0703-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0164679-0983-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0164679-0983-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0164679-0702-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00781-3207-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3208-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3209-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100781-3210-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9327-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-9328-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100781-9329-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 8/31/2015 E0100781-9330-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 6/30/2015 E0100781-3206-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100781-3207-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-9326-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/30/2011 99/99/9999 E0100781-9327-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 8/16/2012 99/99/9999 E0100143-9976-91 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 7.5 GM VIAL 9/1/2010 99/99/9999 E0100143-9977-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 99/99/9999 E0100143-9979-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 99/99/9999 E0100173-0352-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 750 MG VIAL 9/1/2010 2/28/2014 E0100173-0354-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 1.5 GM VIAL 9/1/2010 2/28/2014 E0100173-0400-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 7.5 GM VIAL 9/1/2010 3/31/2013 E0100173-0424-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF-DEXTROSE 750 MG/50 ML 9/1/2010 9/5/2013 E0100173-0425-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 1.5 GRAM/50 ML 9/1/2010 12/30/2014 E0100173-0436-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 750 MG ADD-VANT VIAL 9/1/2010 6/30/2014 E0100173-0437-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 1.5 GM ADD-VANT VIAL 9/1/2010 6/30/2014 E0100264-3112-11 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME 750 MG/50 ML BAG 9/1/2010 3/31/2014 E0100264-3114-11 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME 1.5G/50 ML BAG 9/1/2010 9/30/2014 E0110019-0620-01 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 12/31/2011 E0110019-0620-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 9/30/2013 E0110019-0621-03 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 12/31/2011 E0110019-0621-20 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 9/30/2013 E0163323-0352-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 9/30/2011 E0163323-0353-20 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 9/30/2011 E0163323-0354-61 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 7.5 GM VIAL 9/1/2010 9/30/2011 E0166860-0030-03 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 12/31/2010 E0166860-0031-03 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 12/31/2010 E0166860-0032-02 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 7.5 GM VIAL 9/1/2010 12/31/2010 E0100039-0017-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 500 MG VIAL 9/1/2010 99/99/9999 E0100039-0018-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 9/1/2010 99/99/9999 E0100039-0018-11 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM INFUSION BTL 9/1/2010 12/31/2012 E0100039-0018-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 9/1/2010 9/30/2011 E0100039-0018-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 9/1/2010 9/30/2011 E0100039-0019-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 9/1/2010 99/99/9999 E0100039-0019-11 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM INFUSION BTL 9/1/2010 12/31/2012 E0100039-0019-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 9/1/2010 9/30/2011 E0100039-0019-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 9/1/2010 12/31/2012 E0100039-0020-01 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 10 GM VIAL 9/1/2010 99/99/9999 E0100039-0023-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM ADD-VANTAGE VL 9/1/2010 99/99/9999 E0100039-0023-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM ADD-VANTAGE VL 9/1/2010 9/30/2011 E0100039-0024-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM ADD-VANTAGE VL 9/1/2010 99/99/9999 E0100039-0024-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM ADD-VANTAGE VL 9/1/2010 12/31/2012 E0100039-0037-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM/50 ML GALAXY 9/1/2010 99/99/9999 E0100039-0038-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM/50 ML GALAXY 9/1/2010 99/99/9999 E0100143-9930-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0100143-9931-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9933-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 99/99/9999 E0100143-9935-91 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 10 GM VIAL 9/1/2010 99/99/9999 E0110019-0680-01 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 12/31/2011 E0110019-0680-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 9/30/2013 E0110019-0681-02 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0681-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 9/30/2013 E0110019-0682-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 12/31/2011 E0110019-0682-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 9/30/2013 E0163323-0331-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0332-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 99/99/9999 E0163323-0333-61 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0334-61 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 20 GM VIAL 9/1/2010 9/30/2011 E0163323-0335-10 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0164679-0986-01 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 11/30/2010 E0164679-0986-02 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 12/31/2011 E0164679-0986-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 12/31/2011 E0164679-0986-04 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 9/30/2011 E0100085-0566-05 J0702 INJECTION, BETAMETHASONE ACETATE CELESTONE SOLUSPAN 6 MG/ML 9/1/2010 99/99/9999 E0100574-0823-01 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CIT 60 MG/3 ML VIAL 9/1/2010 7/31/2015 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00574-0823-81 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CIT 60 MG/3 ML VIAL 9/1/2010 99/99/9999 E0151552-0178-05 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CITRATE POWD PURIF 9/1/2010 3/31/2011 E0151552-0178-06 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CITRATE POWD PURIF 9/1/2010 3/31/2011 E0163323-0407-03 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CIT 60 MG/3 ML VIAL 9/1/2010 99/99/9999 E0100007-5085-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GM PIGGYBACK VIAL 9/1/2010 12/31/2010 E0100173-0377-10 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 500 MG VIAL 9/1/2010 2/28/2014 E0100173-0378-10 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 1 GM VIAL 9/1/2010 3/31/2014 E0100173-0379-34 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 2 GM VIAL 9/1/2010 1/31/2014 E0100173-0382-37 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 6 GM VIAL 9/1/2010 11/30/2013 E0100173-0434-00 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 1 GM ADD-VANTAGE VIAL 9/1/2010 4/30/2014 E0100173-0435-00 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 2 GM ADD-VANTAGE VIAL 9/1/2010 5/31/2014 E0100409-5082-16 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5082-52 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5084-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5084-51 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5086-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 6 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5086-51 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 6 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5092-16 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GM ADD-VANTAGE VIAL 9/1/2010 99/99/9999 E0100409-5092-52 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GM ADD-VANTAGE VIAL 9/1/2010 99/99/9999 E0100409-5093-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GM ADD-VANTAGE 9/1/2010 99/99/9999 E0100409-5093-51 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GM ADD-VANTAGE 9/1/2010 99/99/9999 E0100781-3177-96 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3178-95 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 2 GM VIAL 9/1/2010 99/99/9999 E0100781-3179-86 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 6 GM VIAL 9/1/2010 99/99/9999 E0110019-0691-02 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0692-03 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 2 GM VIAL 9/1/2010 12/31/2011 E0110019-0693-04 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 6 GM VIAL 9/1/2010 12/31/2011 E0163323-0011-15 J0720 INJECTION, CHLORAMPHENICOL SODIUM SUCCIN CHLORAMPHEN NA SUCC 1 GM VL 9/1/2010 99/99/9999 E0100052-0315-10 J0725 INJECTION, CHORIONIC GONADOTROPIN PREGNYL 10,000 UNITS VIAL 9/1/2010 99/99/9999 E0155566-1501-01 J0725 INJECTION, CHORIONIC GONADOTROPIN NOVAREL 10,000 UNITS VIAL 9/1/2010 99/99/9999 E0163323-0025-10 J0725 INJECTION, CHORIONIC GONADOTROPIN CHORIONIC GONAD 10,000 UNIT VL 9/1/2010 99/99/9999 E0151552-0480-01 J0735 INJECTION, CLONIDINE HYDROCHLORIDE CLONIDINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0480-02 J0735 INJECTION, CLONIDINE HYDROCHLORIDE CLONIDINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0480-05 J0735 INJECTION, CLONIDINE HYDROCHLORIDE CLONIDINE HCL POWDER 9/1/2010 3/31/2011 E0166479-0520-01 J0735 INJECTION, CLONIDINE HYDROCHLORIDE DURACLON 100 MCG/ML VIAL 9/1/2010 7/31/2012 E0166479-0521-01 J0735 INJECTION, CLONIDINE HYDROCHLORIDE DURACLON 500 MCG/ML VIAL 9/1/2010 7/31/2012 E0161958-0101-01 J0740 INJECTION, CIDOFOVIR, 375 MG. VISTIDE 75 MG/ML VIAL 9/1/2010 5/31/2015 E0100006-3514-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 9/1/2010 99/99/9999 E0100006-3516-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 9/1/2010 99/99/9999 E0100006-3551-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 9/1/2010 99/99/9999 E0100006-3552-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 9/1/2010 99/99/9999 E0100006-3582-75 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN I.M. 500 MG VIAL 9/1/2010 9/30/2011 E0100085-1741-02 J0744 INJECTION, CIPROFLOXACIN CIPRO I.V. 400 MG/200 ML D5W 9/1/2010 11/14/2012 E0100085-1755-02 J0744 INJECTION, CIPROFLOXACIN CIPRO I.V. 200 MG/100 ML D5W 9/1/2010 11/14/2012 E0100409-4765-86 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 200 MG/20 ML VL 9/1/2010 99/99/9999 E0100409-4778-86 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 400 MG/40 ML VL 9/1/2010 99/99/9999 E0100703-0956-03 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 200 MG/20 ML VL 9/1/2010 3/31/2012 E0100703-0958-03 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 400 MG/40 ML VL 9/1/2010 3/31/2012 E0155390-0197-01 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 200 MG/20 ML VL 9/1/2010 9/30/2011 E0155390-0198-01 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 400 MG/40 ML VL 9/1/2010 9/30/2011 E0155390-0199-01 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100406-1548-32 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0100406-1548-35 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0100409-1097-32 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PH 15 MG/ML SYRINGE 9/1/2010 9/30/2011 E0100409-1102-32 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PH 30 MG/ML SYRINGE 9/1/2010 9/30/2011 E0151552-0688-02 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0151552-0688-03 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0151552-0688-04 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0151552-0688-06 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0163304-0748-01 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE 30 MG TAB 9/1/2010 12/31/2012 E0163304-0749-01 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE 60 MG TAB 9/1/2010 12/31/2012 E0100574-0858-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 9/1/2010 99/99/9999 E0139822-0615-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 9/1/2010 99/99/9999 E0155390-0077-01 J0780 INJECTION, PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE 5 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0077-10 J0780 INJECTION, PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE 10 MG/2 ML VL 9/1/2010 3/31/2015 E0155566-0302-01 J0795 INJECTION, CORTICORELIN OVINE TRIFLUTATE ACTHREL 100 MCG VIAL 9/1/2010 99/99/9999 E0163004-7731-01 J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS HP ACTHAR GEL 80 UNIT/ML VIAL 9/1/2010 99/99/9999 E0100781-3440-71 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG COSYNTROPIN 0.25 MG VIAL 7/1/2013 99/99/9999 E0100548-5900-00 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG CORTROSYN 0.25 MG VIAL 9/1/2010 6/30/2014 E0100548-5900-00 J0834 INJECTION, COSYNTROPIN, 0.25 MG CORTROSYN 0.25 MG VIAL 9/1/2010 6/30/2014 E0167919-0011-01 J0878 INJECTION DAPTOMYCIN, 1 MG CUBICIN 500 MG VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

55513-0002-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0002-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0003-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0003-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0004-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0004-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0005-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0005-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0006-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0021-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0021-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0023-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0023-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0025-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0025-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0027-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0027-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0028-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/0.4 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0032-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 500 MCG/1 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0053-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 9/1/2010 99/99/9999 E0155513-0053-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 9/1/2010 99/99/9999 E0155513-0057-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 9/1/2010 99/99/9999 E0155513-0057-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 9/1/2010 99/99/9999 E0155513-0110-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0111-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/0.6 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0025-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0027-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 150 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0057-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/0.42 ML SYRING 9/1/2010 99/99/9999 E0155513-0002-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0003-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 40 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0005-01 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0126-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0126-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0144-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0144-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0148-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0148-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0267-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0267-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0283-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 9/1/2010 99/99/9999 E0155513-0283-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 9/1/2010 99/99/9999 E0155513-0478-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0478-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0302-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 2,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0302-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 2,000 UNITS/ML VIAL 9/1/2010 7/1/2013 E0159676-0303-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 3,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0303-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 3,000 UNITS/ML VIAL 9/1/2010 9/1/2013 E0159676-0304-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 4,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0304-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 4,000 UNITS/ML VIAL 9/1/2010 9/1/2013 E0159676-0310-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0310-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0320-04 J0885 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0340-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 40,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0320-04 J0886 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 5/1/2011 99/99/9999 E0158063-0600-50 J0894 INJECTION, DECITABINE, 1 MG DACOGEN 50 MG VIAL 9/1/2010 8/31/2012 E0100078-0347-51 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL 2 GRAM VIAL 9/1/2010 99/99/9999 E0100078-0467-91 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL MESYLATE 500 MG VL 9/1/2010 99/99/9999 E0100409-2336-10 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 9/1/2010 99/99/9999 E0100409-2337-25 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 9/1/2010 99/99/9999 E0100555-1131-11 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 9/1/2010 3/31/2014 E0100555-1132-12 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 9/1/2010 3/31/2014 E0155390-0263-10 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 9/1/2010 3/31/2014 E0155390-0265-01 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 9/1/2010 7/30/2012 E0151552-0894-02 J0945 INJECTION, BROMPHENIRAMINE MALEATE BROMPHENIRAMINE MALEATE POWDER 9/1/2010 3/31/2011 E0151552-0894-04 J0945 INJECTION, BROMPHENIRAMINE MALEATE BROMPHENIRAMINE MALEATE POWDER 9/1/2010 3/31/2011 E0151552-0894-05 J0945 INJECTION, BROMPHENIRAMINE MALEATE BROMPHENIRAMINE MALEATE POWDER 9/1/2010 3/31/2011 E0100781-3031-75 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE 40 MG/ML VL 9/1/2010 8/31/2011 E0151552-0888-01 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE POWDER 9/1/2010 3/31/2011 E0151552-0888-02 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE POWDER 9/1/2010 3/31/2011 E0151552-0888-04 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE POWDER 9/1/2010 3/31/2011 E0100009-0271-01 J1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP DEPO-ESTRADIOL 5 MG/ML VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00009-0280-02 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0280-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0280-51 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0280-52 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-0031-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100703-0031-04 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100703-0043-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100703-0045-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100781-3132-95 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100781-3132-71 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100781-3137-75 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100703-0051-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100703-0051-04 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100703-0063-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100009-0306-12 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0306-02 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-03 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-23 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0626-01 J1051 INJECTION, MEDROXYPREGESTERONE ACETATE DEPO-PROVERA 400 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-4709-01 J1051 INJECTION, MEDROXYPREGESTERONE ACETATE DEPO-SUBQ PROVERA 104 SYRINGE 9/1/2010 9/30/2013 E0100009-0746-30 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 9/1/2010 12/31/2012 E0100009-0746-35 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 9/1/2010 12/31/2012 E0100009-7376-04 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML SYRN 9/1/2010 12/31/2012 E0100703-6801-01 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0100703-6801-04 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0100703-6811-21 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 4/30/2012 E0159762-4537-01 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0159762-4537-02 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0159762-4538-01 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0100009-0347-02 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO DEPO-TESTOSTERONE 100 MG/ML VL 9/1/2010 99/99/9999 E0100781-3073-70 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO TESTOSTERONE CYP 100 MG/ML 9/1/2010 99/99/9999 E0151552-0104-02 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO TESTOSTERONE CYPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0104-05 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO TESTOSTERONE CYPIONATE POWDER 9/1/2010 3/31/2011 E0100009-0417-01 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC DEPO-TESTOSTERONE 200 MG/ML 9/1/2010 99/99/9999 E0100009-0417-02 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC DEPO-TESTOSTERONE 200 MG/ML 9/1/2010 99/99/9999 E0100591-3223-79 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERON CYP 2,000 MG/10 ML 9/1/2010 99/99/9999 E0100703-6121-01 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 7/31/2011 E0100703-6125-01 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 12/31/2012 E0100781-3074-71 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 99/99/9999 E0100781-3074-70 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 99/99/9999 E0151552-0024-01 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-02 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-03 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-04 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-05 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE POWDER MICRON 9/1/2010 3/31/2011 E0100641-0367-21 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100069-4541-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/16/2012 8/31/2015 E0100069-4543-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/16/2012 3/31/2015 E0100069-4543-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/30/2011 3/31/2015 E0100069-4545-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 8/30/2011 4/30/2015 E0100069-4541-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/30/2011 8/31/2015 E0100517-4901-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-4905-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100517-4930-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 9/1/2010 99/99/9999 E0100641-0367-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-3524-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 2/28/2011 E0100703-3524-03 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 3/31/2011 E0163323-0165-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0165-05 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 9/1/2010 99/99/9999 E0163323-0165-30 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 9/1/2010 99/99/9999 E0163323-0506-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0516-10 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 9/1/2010 99/99/9999 E0100054-3176-44 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE INTENSOL 1MG/1ML 9/1/2010 99/99/9999 E0100574-0850-05 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 9/1/2010 99/99/9999 E0100574-0850-10 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 9/1/2010 99/99/9999 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

51552-0233-01 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE POWDER 9/1/2010 3/31/2011 E0151552-0233-02 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE POWDER 9/1/2010 3/31/2011 E0151552-0233-05 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE POWDER 9/1/2010 3/31/2011 E0155390-0013-10 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML VL 9/1/2010 3/31/2014 E0166490-0041-01 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG D.H.E.45 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0155390-0460-01 J1120 INJECTION, ACETAZOLAMIDE SODIUM, UP TO 5 ACETAZOLAMIDE SOD 500 MG VIAL 9/1/2010 3/31/2014 E0100173-0260-10 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG LANOXIN 500 MCG/2 ML AMPULE 9/1/2010 3/31/2014 E0100173-0260-35 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG LANOXIN 0.25 MG/ML AMPUL 9/1/2010 9/30/2012 E0100173-0262-10 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG LANOXIN PED 0.1 MG/ML AMPUL 9/1/2010 7/31/2014 E0100409-2169-31 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 0.25 MG/ML SYRINGE 9/1/2010 9/30/2011 E0100641-1410-35 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 0.25 MG/ML AMPUL 9/1/2010 99/99/9999 E0100781-3059-95 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 0.25 MG/ML AMPUL 9/1/2010 99/99/9999 E0100173-0230-44 J1162 INJECTION,DIGOXIN IMMUNE FAB DIGIBIND 38 MG VIAL 9/1/2010 1/31/2013 E0100281-0365-10 J1162 INJECTION,DIGOXIN IMMUNE FAB DIGIFAB 40 MG VIAL 9/1/2010 8/31/2012 E0100143-9881-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 250 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100143-9882-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 100 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-1317-01 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML AMPUL 9/1/2010 9/30/2011 E0100409-1317-02 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-1844-32 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML SYRINGE 9/1/2010 6/30/2014 E0100641-0493-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-2555-45 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-7101-04 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG FOSPHENYTOIN 100 MG PE/2 ML VL 9/1/2010 8/31/2011 E0100703-7105-03 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG FOSPHENYTOIN 500 MG PE/10 ML 9/1/2010 3/31/2011 E0151552-0532-04 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN SODIUM POWDER 9/1/2010 3/31/2011 E0160505-0765-04 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG FOSPHENYTOIN 500 MG PE/10 ML 9/1/2010 99/99/9999 E0117478-0540-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML VL 11/10/2010 99/99/9999 E0100409-2634-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2634-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100409-2634-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 500 MG/50 ML VIA 9/1/2010 99/99/9999 E0159011-0441-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0442-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0442-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0444-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0445-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0445-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0445-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML VIAL 9/1/2010 99/99/9999 E0159011-0446-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 250 MG VIAL 9/1/2010 99/99/9999 E0100074-2332-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 9/1/2010 3/31/2011 E0100074-2333-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 3/31/2011 E0100074-2333-26 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 3/1/2011 E0100074-2334-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 9/1/2010 3/31/2011 E0100406-3245-52 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 9/1/2010 3/31/2011 E0100409-1283-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-1304-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 4 MG/ML SYRIN 9/1/2010 99/99/9999 E0100409-1312-30 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-2172-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 9/1/2010 7/1/2011 E0100409-2172-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 9/1/2010 9/30/2011 E0100409-2540-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 4 MG/ML AMP 9/1/2010 99/99/9999 E0100409-2552-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 1 MG/ML AMP 9/1/2010 99/99/9999 E0100409-3356-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 2 MG/ML AMP 9/1/2010 99/99/9999 E0100409-3365-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100555-1117-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 8/31/2011 E0100555-1117-06 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100555-1117-07 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 6/30/2011 E0100574-2017-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 9/1/2010 3/31/2011 E0100641-0121-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-2341-41 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0138779-0731-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 9/1/2010 3/31/2011 E0100641-0121-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100013-8715-62 J1190 INJECTION, DEXTAZOXANE HCL ZINECARD 250 MG VIAL 9/1/2010 12/31/2012 E0100013-8725-89 J1190 INJECTION, DEXTAZOXANE HCL ZINECARD 500 MG VIAL 9/1/2010 12/31/2012 E0155390-0014-02 J1190 INJECTION, DEXTAZOXANE HCL DEXRAZOXANE 250 MG VIAL 9/1/2010 3/31/2014 E0155390-0060-02 J1190 INJECTION, DEXTAZOXANE HCL DEXRAZOXANE 500 MG VIAL 9/1/2010 5/31/2013 E0100409-2290-31 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML SYRNG 9/1/2010 99/99/9999 E0100548-1390-00 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML SYN 9/1/2010 3/31/2011 E0100641-0376-25 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0124-02 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0124-04 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0124-05 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0124-06 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0163323-0664-01 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

67386-0711-55 J1205 INJECTION, CHLOROTHIAZIDE SODIUM DIURIL SODIUM 500 MG VIAL 9/1/2010 11/30/2012 E0151552-1053-06 J1212 INJECTION, DMSO, DIMETHYL SULFOXIDE DIMETHYL SULFOXIDE LIQUID 9/1/2010 3/31/2011 E0100406-1510-56 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0100406-1510-57 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0100406-1510-59 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0151552-0728-01 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0151552-0728-02 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0151552-0728-04 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0166479-0530-02 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL 10 MG/ML VIAL 9/1/2010 9/30/2011 E0163323-0366-01 J1240 INJECTION, DIMENHYDRINATE, UP TO 50 MG DIMENHYDRINATE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-2569-44 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-1652-02 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 12/31/2010 E0100703-1654-02 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 12/31/2010 E0155390-0555-10 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0555-90 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 9/30/2011 E0100338-1073-02 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1075-02 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1077-02 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 9/1/2010 99/99/9999 E0100409-2025-20 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2025-54 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2344-01 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2344-02 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2344-88 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2346-32 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-2346-34 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 500 ML 9/1/2010 9/30/2011 E0100409-2347-32 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-2347-33 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-3724-32 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 9/1/2010 99/99/9999 E0155390-0560-90 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 3/31/2014 E0100088-1206-32 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100088-1208-06 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100088-1208-69 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 9/1/2010 9/30/2013 E0100088-1209-26 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100264-1441-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 500 ML 9/1/2010 3/31/2011 E0100264-1481-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 500 ML 9/1/2010 3/31/2011 E0100264-1482-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE-D5W 400 MG/250 ML 9/1/2010 8/31/2012 E0100264-1492-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 250 ML 9/1/2010 3/31/2011 E0100338-1005-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 200 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1005-03 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100338-1007-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1007-03 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100338-1009-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-4142-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 250 ML 9/1/2010 9/30/2011 E0100409-4265-01 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 80 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-5820-01 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-7808-22 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 200 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-7808-24 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100409-7809-22 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-7809-24 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100409-7810-22 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-9104-20 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-1305-25 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 160 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-1805-25 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-1905-25 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100062-4010-02 J1267 DORIPENEM INJECTION DORIBAX 500 MG VIAL 9/1/2010 2/28/2011 E0158468-0126-01 J1270 INJECTION, DOXERCALCIFEROL, 1 MCG HECTOROL 2 MCG/ML VIAL 1/1/2011 99/99/9999 E0158468-0122-01 J1270 INJECTION, DOXERCALCIFEROL, 1 MCG HECTOROL 4 MCG/2 ML AMPUL 9/1/2010 9/30/2010 E0125682-0001-01 J1300 INJECTION, ECULIZUMAB, 10 MG SOLIRIS 300 MG/30 ML VIAL 9/1/2010 99/99/9999 E0151552-0464-02 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0464-04 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0464-05 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0464-06 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0100004-0380-39 J1324 INJECTION, ENFUVIRTIDE, 1 MG FUZEON CONVENIENCE KIT 9/1/2010 6/30/2013 E0100173-0517-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 0.5 MG VIAL 9/1/2010 99/99/9999 E0100173-0519-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 1.5 MG VIAL 9/1/2010 99/99/9999 E0151552-0188-01 J1330 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 ERGONOVINE MALEATE POWDER 9/1/2010 3/31/2011 E0151552-0188-07 J1330 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 ERGONOVINE MALEATE POWDER 9/1/2010 3/31/2011 E0100006-3843-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM VIAL 9/1/2010 99/99/9999 E0100006-3845-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM ADD-VANTAGE VIAL 9/1/2010 99/99/9999 E0100409-6476-44 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG ADDVNT VL 9/1/2010 99/99/9999 E0100409-6478-44 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 1 GM ADDVANT VIAL 9/1/2010 9/30/2011 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00409-6482-01 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3030-75 J1380 INJECTION, ESTRADIOL VALERATE, UP TO 10 ESTRADIOL VALERATE 10 MG/ML VL 9/1/2010 12/31/2012 E0100781-3029-75 J1390 INJECTION, ESTRADIOL VALERATE, UP TO 20 ESTRADIOL VALERATE 20 MG/ML VL 9/1/2010 3/31/2013 E0100046-0749-05 J1410 INJECTION, ESTROGEN CONJUGATED PREMARIN 25 MG VIAL 9/1/2010 99/99/9999 E0151552-0445-01 J1435 INJECTION, ESTRONE, PER 1 MG ESTRONE CRYSTAL 9/1/2010 3/31/2011 E0151552-0445-02 J1435 INJECTION, ESTRONE, PER 1 MG ESTRONE CRYSTAL 9/1/2010 3/31/2011 E0151552-0445-04 J1435 INJECTION, ESTRONE, PER 1 MG ESTRONE CRYSTAL 9/1/2010 3/31/2011 E0158406-0425-34 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG KIT 9/1/2010 99/99/9999 E0158406-0425-41 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG KIT 9/1/2010 99/99/9999 E0158406-0435-01 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SYRINGE 9/1/2010 99/99/9999 E0158406-0435-04 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SYRINGE 9/1/2010 99/99/9999 E0158406-0445-01 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SURECLICK SYR 9/1/2010 99/99/9999 E0158406-0445-04 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SURECLICK SYR 9/1/2010 99/99/9999 E0158406-0455-01 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0158406-0455-04 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0530-01 J1440 NJECTION, FILGRASTIM NEUPOGEN 300 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0530-10 J1440 NJECTION, FILGRASTIM NEUPOGEN 300 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0924-01 J1440 NJECTION, FILGRASTIM NEUPOGEN 300 MCG/0.5 ML SYR 9/1/2010 99/99/9999 E0155513-0924-10 J1440 NJECTION, FILGRASTIM NEUPOGEN 300 MCG/0.5 ML SYR 9/1/2010 99/99/9999 E0155513-0209-01 J1441 INJECTION, FILGRASTIM NEUPOGEN 480 MCG/0.8 ML SYR 9/1/2010 99/99/9999 E0155513-0209-10 J1441 INJECTION, FILGRASTIM NEUPOGEN 480 MCG/0.8 ML SYR 9/1/2010 99/99/9999 E0155513-0546-01 J1441 INJECTION, FILGRASTIM NEUPOGEN 480 MCG/1.6 ML VIAL 9/1/2010 99/99/9999 E0155513-0546-10 J1441 INJECTION, FILGRASTIM NEUPOGEN 480 MCG/1.6 ML VIAL 9/1/2010 99/99/9999 E0100049-3371-26 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M DIFLUCAN-SALINE 200 MG/100 ML 9/1/2010 3/31/2011 E0100049-3372-26 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M DIFLUCAN-SALINE 400 MG/200 ML 9/1/2010 11/1/2014 E0100049-3435-26 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M DIFLUCAN-SALINE 200 MG/100 ML 9/1/2010 7/31/2011 E0100049-3436-26 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M DIFLUCAN-SALINE 400 MG/200 ML 9/1/2010 7/31/2011 E0100049-3438-26 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M DIFLUCAN-DEXTR 400 MG/200 ML 9/1/2010 7/31/2011 E0100338-6045-37 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 99/99/9999 E0100338-6046-48 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 99/99/9999 E0100409-4684-02 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-DEXT 400 MG/200 ML 9/1/2010 99/99/9999 E0100409-4684-23 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-DEXT 200 MG/100 ML 9/1/2010 99/99/9999 E0100409-4688-02 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 99/99/9999 E0100409-4688-23 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 99/99/9999 E0100409-4688-27 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 9/30/2011 E0100409-4688-28 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 99/99/9999 E0100409-4688-33 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 9/30/2011 E0100409-4688-34 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 99/99/9999 E0100703-1010-09 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 9/5/2013 E0100703-1019-09 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 9/5/2013 E0100703-1020-30 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 99/99/9999 E0100703-1029-30 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 99/99/9999 E0151552-1031-01 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE POWDER 9/1/2010 3/31/2011 E0151552-1031-02 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE POWDER 9/1/2010 3/31/2011 E0155390-0012-01 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 3/31/2014 E0155390-0046-01 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 3/31/2014 E0161703-0414-63 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 200 MG/100 ML 9/1/2010 9/30/2011 E0161703-0414-64 J1450 INJECTION, FLUCONAZOLE (DIFLUCAN), 200 M FLUCONAZOLE-NS 400 MG/200 ML 9/1/2010 9/30/2011 E0162161-0003-34 J1451 INJECTION, FOMEPIZOLE, 15 MG ANTIZOL 1 GM/ML VIAL 9/1/2010 2/28/2011 E0168727-0200-02 J1451 INJECTION, FOMEPIZOLE, 15 MG ANTIZOL 1.5 GM/1.5 ML VIAL 9/1/2010 6/30/2012 E0100006-3941-32 J1453 INJECTION, FOSAPREPITANT, 1 MG EMEND 150 MG VIAL 11/15/2010 99/99/9999 E0100006-3884-32 J1453 INJECTION, FOSAPREPITANT, 1 MG EMEND 115 MG VIAL 9/1/2010 7/31/2012 E0100409-3863-02 J1455 INJECTION, FOSCARNET SODIUM, PER 1000 MG FOSCARNET 24 MG/ML INFUS BTTL 9/1/2010 6/30/2014 E0100409-3863-05 J1455 INJECTION, FOSCARNET SODIUM, PER 1000 MG FOSCARNET 24 MG/ML INFUS BTTL 9/1/2010 6/30/2014 E0168135-0020-01 J1458 INJECTION, GALSULFASE, 1 MG NAGLAZYME 5 MG/5 ML VIAL 9/1/2010 99/99/9999 E0113533-0635-04 J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR GAMASTAN S-D VIAL 9/1/2010 99/99/9999 E0113533-0635-12 J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR GAMASTAN S-D VIAL 9/1/2010 99/99/9999 E0113533-0645-12 J1561 GAMUNEX-C/GAMMAKED GAMUNEX 10% VIAL 9/1/2010 3/24/2013 E0113533-0645-15 J1561 GAMUNEX-C/GAMMAKED GAMUNEX 10% VIAL 9/1/2010 4/19/2013 E0113533-0645-20 J1561 GAMUNEX-C/GAMMAKED GAMUNEX 10% VIAL 9/1/2010 6/26/2014 E0113533-0645-24 J1561 GAMUNEX-C/GAMMAKED GAMUNEX 10% VIAL 9/1/2010 10/17/2013 E0113533-0645-71 J1561 GAMUNEX-C/GAMMAKED GAMUNEX 10% VIAL 9/1/2010 10/22/2013 E0100053-7596-03 J1562 VIVAGLOBIN, INJ VIVAGLOBIN 16% VIAL 9/1/2010 3/31/2011 E0100053-7596-10 J1562 VIVAGLOBIN, INJ VIVAGLOBIN 16% VIAL 9/1/2010 5/6/2013 E0100053-7596-15 J1562 VIVAGLOBIN, INJ VIVAGLOBIN 16% VIAL 9/1/2010 12/31/2010 E0100053-7596-20 J1562 VIVAGLOBIN, INJ VIVAGLOBIN 16% VIAL 9/1/2010 6/8/2013 E0100053-7596-25 J1562 VIVAGLOBIN, INJ VIVAGLOBIN 16% VIAL 9/1/2010 12/31/2010 E0161953-0005-02 J1566 INJECTION, IMMUNE GLOBULIN FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 E0100944-2655-03 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 G (IGA<1) SOLN 9/1/2010 99/99/9999 E0100944-2655-04 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 G (IGA<1) SOL 9/1/2010 99/99/9999 E0100944-0471-75 J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 5 GM VIAL-DILUE 9/1/2010 12/31/2010 E01

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00944-0471-80 J1566 INJECTION, IMMUNE GLOBULIN POLYGAM S-D 10 GM VIAL-DILU 9/1/2010 12/31/2010 E0100944-2620-01 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 0.5 GM VL W-ST 9/1/2010 12/31/2012 E0100944-2620-02 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 2.5 GM VL W/ST 9/1/2010 5/25/2013 E0100944-2620-03 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 5 GM VL W/SET 9/1/2010 4/11/2014 E0100944-2620-04 J1566 INJECTION, IMMUNE GLOBULIN GAMMAGARD S-D 10 GM VL W/ST 9/1/2010 6/21/2014 E0144206-0416-03 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 3 GM VIAL 9/1/2010 6/3/2014 E0144206-0417-06 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 6 GM VIAL 9/1/2010 99/99/9999 E0144206-0418-12 J1566 INJECTION, IMMUNE GLOBULIN CARIMUNE NF 12 GM VIAL 9/1/2010 99/99/9999 E0164193-0250-50 J1566 INJECTION, IMMUNE GLOBULIN IVEEGAM EN 5 GM VIAL 9/1/2010 12/31/2010 E0100944-2700-02 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 9/1/2010 99/99/9999 E0100944-2700-03 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 9/1/2010 99/99/9999 E0100944-2700-04 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 9/1/2010 99/99/9999 E0100944-2700-05 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 9/1/2010 99/99/9999 E0100944-2700-06 J1569 GAMMAGARD LIQUID INJECTION GAMMAGARD LIQUID 10% VIAL 9/1/2010 99/99/9999 E0100004-6940-03 J1570 INJECTION, GANCICLOVIR SODIUM CYTOVENE 500 MG VIAL 9/1/2010 99/99/9999 E0161953-0005-02 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA DIF 10% VIAL 2/8/2011 99/99/9999 E0161953-0005-03 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA DIF 10% VIAL 11/15/2010 99/99/9999 E0161953-0003-01 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA 5% VIAL 9/1/2010 12/31/2010 E0161953-0003-02 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA 5% VIAL 9/1/2010 12/31/2010 E0161953-0003-03 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA 5% VIAL 9/1/2010 12/31/2010 E0161953-0003-04 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA 5% VIAL 9/1/2010 12/31/2010 E0161953-0004-01 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA DIF 5% VIAL 9/1/2010 99/99/9999 E0161953-0004-02 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA DIF 5% VIAL 9/1/2010 99/99/9999 E0161953-0004-03 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA DIF 5% VIAL 9/1/2010 99/99/9999 E0161953-0004-04 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA DIF 5% VIAL 9/1/2010 99/99/9999 E0161953-0004-05 J1572 FLEBOGAMMA INJECTION FLEBOGAMMA DIF 5% VIAL 9/1/2010 99/99/9999 E0100264-5806-32 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 60 MG/NS 100 ML PB 9/1/2010 3/31/2011 E0100264-5808-32 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 100 ML PB 9/1/2010 3/31/2013 E0100264-5810-32 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 100 MG/NS 100 ML 9/1/2010 4/30/2013 E0100264-5812-38 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 60 MG/NS 50 ML PB 9/1/2010 8/31/2012 E0100264-5816-38 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 50 ML PB 9/1/2010 4/30/2013 E0100338-0501-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 60 MG/100 ML 9/1/2010 11/30/2010 E0100338-0503-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 80 MG/100 ML 9/1/2010 99/99/9999 E0100338-0505-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISO GENTAMICIN 100 MG/100 ML 9/1/2010 99/99/9999 E0100338-0507-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 60 MG/50 ML 9/1/2010 99/99/9999 E0100338-0507-48 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISO GENTAMICIN 120 MG/100 ML 9/1/2010 99/99/9999 E0100338-0509-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 80 MG/50 ML 9/1/2010 99/99/9999 E0100338-0511-41 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO ISOTON GENTAMICIN 100 MG/50 ML 9/1/2010 99/99/9999 E0100409-1207-03 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-3400-01 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-3401-01 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-3402-01 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-7879-13 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 60 MG/NS 50 ML PB 9/1/2010 99/99/9999 E0100409-7881-13 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 70 MG/NS 50 ML PB 9/1/2010 9/30/2011 E0100409-7883-13 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 50 ML PB 9/1/2010 99/99/9999 E0100409-7884-23 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/NS 100 ML PB 9/1/2010 99/99/9999 E0100409-7886-23 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 90 MG/NS 100 ML PB 9/1/2010 9/30/2011 E0100409-7889-23 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 100 MG/NS 100 ML 9/1/2010 99/99/9999 E0163323-0010-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 80 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0010-20 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 40 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0173-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN PED 20 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0513-02 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO GENTAMICIN 20 MG/2 ML VIAL 9/1/2010 99/99/9999 E0111098-0533-01 J1600 INJECTION, GOLD SODIUM THIOMALEATE, UP T MYOCHRYSINE 50 MG/ML VIAL 9/1/2010 3/31/2011 E0111098-0533-10 J1600 INJECTION, GOLD SODIUM THIOMALEATE, UP T MYOCHRYSINE 50 MG/ML VIAL 9/1/2010 12/31/2010 E0100002-8031-01 J1610 INJECTION,GLUCAGON GLUCAGON 1 MG EMERGENCY KIT 9/1/2010 99/99/9999 E0100169-7065-15 J1610 INJECTION,GLUCAGON GLUCAGEN 1 MG HYPOKIT 9/1/2010 99/99/9999 E0155390-0004-01 J1610 INJECTION,GLUCAGON GLUCAGEN 1 MG VIAL 9/1/2010 99/99/9999 E0155390-0004-10 J1610 INJECTION,GLUCAGON GLUCAGEN 1 MG VIAL 9/1/2010 99/99/9999 E0155390-0250-10 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 9/1/2010 9/30/2011 E0163323-0318-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0319-04 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 9/1/2010 99/99/9999 E0166758-0035-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0166758-0036-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 9/1/2010 99/99/9999 E0166758-0037-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 9/1/2010 12/31/2010 E0100703-7973-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 4 MG/4 ML VIAL 9/1/2010 99/99/9999 E0163323-0317-01 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-7891-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 9/1/2010 12/31/2010 E0100703-7971-03 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0160505-0764-02 J1626 INJECTION, GRANISETRON HYDROCHLORIDE GRANISETRON HCL 0.1 MG/ML VIAL 9/1/2010 99/99/9999 E0100004-0240-09 J1626 INJECTION, GRANISETRON HYDROCHLORIDE KYTRIL 4 MG/4 ML VIAL 9/1/2010 11/30/2011 E0100045-0255-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALDOL 5 MG/ML AMPUL 9/1/2010 7/31/2011 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00703-7041-03 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 10/31/2012 E0100703-7045-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0519-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL POWDER 9/1/2010 3/31/2011 E0151552-0519-02 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL POWDER 9/1/2010 3/31/2011 E0155390-0147-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0147-10 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 4/30/2013 E0155390-0447-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0447-10 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 12/31/2010 E0163323-0474-01 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0474-10 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0474-91 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG HALOPERIDOL LAC 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100045-0253-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 9/1/2010 3/31/2011 E0100045-0253-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 50 AMPUL 9/1/2010 3/31/2011 E0100045-0254-14 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALDOL DECANOATE 100 AMPUL 9/1/2010 5/31/2011 E0100703-7011-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-7013-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-7021-03 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-7023-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 9/1/2010 99/99/9999 E0155390-0412-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0412-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0413-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0413-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 9/1/2010 9/30/2011 E0160505-0702-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 9/1/2010 99/99/9999 E0160505-0703-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0469-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0469-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 50 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0471-01 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0471-05 J1631 HALOPERIDOL DECANOATE, PER 50 MG HALOPERIDOL DEC 100 MG/ML VIAL 9/1/2010 99/99/9999 E0167386-0701-54 J1640 INJECTION, HEMIN PANHEMATIN 313 MG VIAL 9/1/2010 9/30/2015 E0100409-1151-12 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 100 UNIT/10 ML (10/ML) 9/1/2010 9/30/2011 E0100409-1151-70 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 100 UNIT/10 ML (10/ML) 9/1/2010 6/30/2014 E0100409-1151-78 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 300 UNIT/30 ML (10/ML) 9/1/2010 12/31/2012 E0100409-1152-12 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 1,000 UNIT/10 (100/ML) 9/1/2010 7/1/2011 E0100409-1152-70 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 1,000 UNIT/10 (100/ML) 9/1/2010 6/30/2014 E0100409-1152-78 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 3,000 UNIT/30 (100/ML) 9/1/2010 6/1/2013 E0100409-1280-31 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN LOCK FLUSH 10 UNITS/ML 9/1/2010 11/1/2013 E0100409-1280-32 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 20 UNITS/2 ML (10/ML) 9/1/2010 6/30/2014 E0100409-1280-33 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 30 UNIT/3 ML (10/ML) 9/1/2010 6/30/2014 E0100409-1280-35 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 50 UNITS/5 ML (10/ML) 9/1/2010 6/30/2014 E0100409-1281-31 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN LOCK FLUSH 100 UNIT/ML 9/1/2010 11/1/2013 E0100409-1281-32 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 200 UNIT/2 ML (100/ML) 9/1/2010 8/1/2013 E0100409-1281-33 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 300 UNIT/3 ML (100/ML) 9/1/2010 7/1/2013 E0100409-1281-35 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEPARIN 500 UNIT/5 ML (100/ML) 9/1/2010 6/30/2014 E0100641-0273-21 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEP-LOCK U-P 100 UNITS/ML VIAL 9/1/2010 12/31/2010 E0100641-0273-25 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK HEP-LOCK U-P 100 UNITS/ML VIAL 9/1/2010 12/31/2010 E0100264-9567-10 J1644 INJECTION, HEPARIN HEPARIN-D5W 20,000 UNIT/500 ML 9/1/2010 99/99/9999 E0100264-9577-10 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/500 ML 9/1/2010 99/99/9999 E0100264-9587-20 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/250 ML 9/1/2010 99/99/9999 E0100264-9872-10 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 9/1/2010 99/99/9999 E0100338-0431-03 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 9/1/2010 99/99/9999 E0100338-0433-04 J1644 INJECTION, HEPARIN HEPARIN-NS 2,000 UNIT/1,000 ML 9/1/2010 99/99/9999 E0100338-0549-03 J1644 INJECTION, HEPARIN HEPARIN-D5W 20,000 UNIT/500 ML 9/1/2010 3/31/2011 E0100338-0550-02 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/250 ML 9/1/2010 3/31/2011 E0100338-0550-03 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/500 ML 9/1/2010 3/31/2011 E0100409-1316-25 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/0.5 ML 9/1/2010 10/1/2012 E0100409-1316-32 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/0.5 ML 9/1/2010 11/1/2014 E0100409-1316-66 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/0.5 ML 9/1/2010 9/30/2011 E0100409-1402-31 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/ML SYR 9/1/2010 7/1/2012 E0100409-2581-02 J1644 INJECTION, HEPARIN HEPARIN 10,000 UNITS/5 ML VL 9/1/2010 7/1/2011 E0100409-2584-02 J1644 INJECTION, HEPARIN HEPARIN 25,000 UNITS/10 ML VL 9/1/2010 9/30/2011 E0100409-7620-03 J1644 INJECTION, HEPARIN HEPARIN-NS 1,000 UNITS/500 ML 9/1/2010 99/99/9999 E0100409-7620-59 J1644 INJECTION, HEPARIN HEPARIN-NS 2,000 UNIT/1,000 ML 9/1/2010 99/99/9999 E0100409-7650-62 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 25,000 UNITS/250 9/1/2010 99/99/9999 E0100409-7651-03 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 25,000 UNITS/500 9/1/2010 99/99/9999 E0100409-7651-62 J1644 INJECTION, HEPARIN HEPARIN-1/2NS 12,500 UNITS/250 9/1/2010 99/99/9999 E0100409-7760-03 J1644 INJECTION, HEPARIN HEPARIN-D5W 20,000 UNIT/500 ML 9/1/2010 99/99/9999 E0100409-7761-03 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/500 ML 9/1/2010 99/99/9999 E0100409-7793-23 J1644 INJECTION, HEPARIN HEPARIN-D5W 10,000 UNIT/100 ML 9/1/2010 9/30/2011 E0100409-7793-62 J1644 INJECTION, HEPARIN HEPARIN-D5W 25,000 UNIT/250 ML 9/1/2010 99/99/9999 E0100409-7794-62 J1644 INJECTION, HEPARIN HEPARIN-D5W 12,500 UNIT/250 ML 9/1/2010 99/99/9999 E0163323-0047-10 J1644 INJECTION, HEPARIN HEPARIN 50,000 UNITS/10 ML VL 9/1/2010 99/99/9999 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

63323-0262-01 J1644 INJECTION, HEPARIN HEPARIN SOD 5,000 UNIT/ML VIAL 9/1/2010 99/99/9999 E0163323-0276-02 J1644 INJECTION, HEPARIN HEPARIN 2,000 UNIT/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0540-01 J1644 INJECTION, HEPARIN HEPARIN SOD 1,000 UNIT/ML VIAL 9/1/2010 99/99/9999 E0163323-0540-11 J1644 INJECTION, HEPARIN HEPARIN 10,000 UNIT/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0540-31 J1644 INJECTION, HEPARIN HEPARIN 30,000 UNIT/30 ML VIAL 9/1/2010 99/99/9999 E0163323-0542-01 J1644 INJECTION, HEPARIN HEPARIN SOD 10,000 UNIT/ML VL 9/1/2010 99/99/9999 E0163323-0542-07 J1644 INJECTION, HEPARIN HEPARIN 50,000 UNITS/5 ML VIAL 9/1/2010 99/99/9999 E0163323-0915-01 J1644 INJECTION, HEPARIN HEPARIN SOD 20,000 UNIT/ML VL 9/1/2010 99/99/9999 E0162856-0101-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 10,000 UNITS SYRINGE 9/1/2010 99/99/9999 E0162856-0102-01 J1645 INJECTION, DALTEPARIN NA FRAGMIN 10,000 UNITS/ML VIAL 9/1/2010 3/31/2011 E0162856-0125-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 12,500 UNITS SYRINGE 9/1/2010 99/99/9999 E0162856-0150-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 15,000 UNITS SYRINGE 9/1/2010 99/99/9999 E0162856-0180-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 18,000 UNITS SYRINGE 9/1/2010 99/99/9999 E0162856-0250-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 2,500 UNITS SYRINGE 9/1/2010 99/99/9999 E0162856-0251-01 J1645 INJECTION, DALTEPARIN NA FRAGMIN 25,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0162856-0500-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 5,000 UNITS SYRINGE 9/1/2010 99/99/9999 E0162856-0750-10 J1645 INJECTION, DALTEPARIN NA FRAGMIN 7,500 UNITS SYRINGE 9/1/2010 99/99/9999 E0100075-0620-40 J1650 ENOXAPARIN SODIUM LOVENOX 40 MG/0.4 ML SYRINGE 9/1/2010 99/99/9999 E0100075-0621-60 J1650 ENOXAPARIN SODIUM LOVENOX 60 MG/0.6 ML SYRINGE 9/1/2010 99/99/9999 E0100075-0622-80 J1650 ENOXAPARIN SODIUM LOVENOX 80 MG/0.8 ML SYRINGE 9/1/2010 99/99/9999 E0100075-0623-00 J1650 ENOXAPARIN SODIUM LOVENOX 100 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100075-0624-30 J1650 ENOXAPARIN SODIUM LOVENOX 30 MG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0100075-0626-03 J1650 ENOXAPARIN SODIUM LOVENOX 300 MG/3 ML VIAL 9/1/2010 99/99/9999 E0100075-2912-01 J1650 ENOXAPARIN SODIUM LOVENOX 120 MG/0.8 ML SYRINGE 9/1/2010 99/99/9999 E0100075-2915-01 J1650 ENOXAPARIN SODIUM LOVENOX 150 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100007-3230-02 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 2.5 MG SYRINGE 9/1/2010 4/30/2014 E0100007-3230-11 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 2.5 MG SYRINGE 9/1/2010 99/99/9999 E0100007-3232-02 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 5 MG SYRINGE 9/1/2010 8/31/2013 E0100007-3232-11 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 5 MG SYRINGE 9/1/2010 99/99/9999 E0100007-3234-02 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 7.5 MG SYRINGE 9/1/2010 3/31/2014 E0100007-3234-11 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 7.5 MG SYRINGE 9/1/2010 99/99/9999 E0100007-3236-02 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 10 MG SYRINGE 9/1/2010 4/30/2014 E0100007-3236-11 J1652 INJECTION, FONDAPARINUX SODIUM ARIXTRA 10 MG SYRINGE 9/1/2010 99/99/9999 E0167211-0342-08 J1655 INJECTION INNOHEP 20,000 UNIT/ML VIAL 9/1/2010 7/31/2011 E0167211-0342-53 J1655 INJECTION INNOHEP 20,000 UNIT/ML VIAL 9/1/2010 9/30/2011 E0113533-0634-02 J1670 INJECTION, TETANUS IMMUNCE GLOBULIN HYPERTET S-D 250 UNITS SYRINGE 9/1/2010 99/99/9999 E0100574-0421-01 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWDER 9/1/2010 3/31/2011 E0100574-0421-25 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWDER 9/1/2010 3/31/2011 E0139822-5090-01 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWD 9/1/2010 12/31/2010 E0139822-5090-03 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWD 9/1/2010 12/31/2010 E0139822-5090-05 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWD 9/1/2010 12/31/2010 E0151552-0021-01 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0021-02 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0021-03 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0021-04 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0021-05 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO HYDROCORTISONE ACETATE POWDER 9/1/2010 3/31/2011 E0100009-0825-01 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 100 MG VIAL 9/1/2010 99/99/9999 E0100009-0900-13 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 100 MG ACT-O-VL 9/1/2010 11/1/2014 E0100009-0900-20 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 100 MG ACT-O-VL 9/1/2010 2/1/2015 E0100009-0909-08 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 250 MG ACT-O-VL 9/1/2010 7/1/2014 E0100009-0909-16 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 250 MG ACT-O-VL 9/1/2010 99/99/9999 E0100009-0912-05 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 500 MG ACT-O-VL 9/1/2010 7/1/2014 E0100009-0920-03 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA SOLU-CORTEF 1,000 MG ACT-O-VL 9/1/2010 5/1/2014 E0100409-4856-05 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINA A-HYDROCORT 100 MG VIAL 9/1/2010 99/99/9999 E0100004-0188-09 J1740 INJECTION, IBANDRONATE SODIUM, 1 MG BONIVA 3 MG/3 ML SYRINGE 9/1/2010 9/30/2012 E0100009-3794-01 J1742 INJECTION, IBUTILIDE FUMARATE, 1 MG CORVERT 1 MG/10 ML VIAL 9/1/2010 99/99/9999 E0154092-0700-01 J1743 INJECTION, IDURSULFASE, 1 MG ELAPRASE 6 MG/3 ML VIAL 9/1/2010 99/99/9999 E0157894-0030-01 J1745 INJECTION, INFLIZIMAB (REMICADE), 10MG REMICADE 100 MG VIAL 9/1/2010 99/99/9999 E0152544-0931-02 J1750 INJECTION, IRON DEXTRAN, 50 MG INFED 100 MG/2 ML VIAL 9/1/2010 99/99/9999 E0149230-0534-10 J1750 INJECTION, IRON DEXTRAN, 50 MG VENOFER 100 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100517-0234-10 J1750 INJECTION, IRON DEXTRAN, 50 MG DEXFERRUM 100 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100517-2310-05 J1756 INJECTION, IRON SUCROSE, 1 MG VENOFER 200 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100517-2340-10 J1756 INJECTION, IRON SUCROSE, 1 MG VENOFER 100 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100517-2340-25 J1756 INJECTION, IRON SUCROSE, 1 MG VENOFER 100 MG/5 ML VIAL 9/1/2010 99/99/9999 E0149230-0530-10 J1756 INJECTION, IRON SUCROSE, 1 MG VENOFER 50 MG/2.5 ML VIAL 2/8/2011 99/99/9999 E0149230-0530-25 J1756 INJECTION, IRON SUCROSE, 1 MG VENOFER 50 MG/2.5 ML VIAL 8/29/2012 99/99/9999 E0149230-0534-10 J1756 INJECTION, IRON SUCROSE, 1 MG VENOFER 100 MG/5 ML VIAL 9/1/2010 99/99/9999 E0158468-1983-01 J1785 INIGLUCERASE INJECTION, PER UNIT CEREZYME 200 UNITS VIAL 9/1/2010 12/31/2012 E0158468-4663-01 J1785 INIGLUCERASE INJECTION, PER UNIT CEREZYME 400 UNITS VIAL 9/1/2010 99/99/9999 E0100409-1187-01 J1790 INJECTION, DROPERIDOL, UP TO 5 MG DROPERIDOL 2.5 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-9702-25 J1790 INJECTION, DROPERIDOL, UP TO 5 MG DROPERIDOL 2.5 MG/ML VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00781-3777-95 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG PROPRANOLOL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0155390-0003-10 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG PROPRANOLOL 1 MG/ML VIAL 9/1/2010 3/31/2014 E0163323-0604-01 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG PROPRANOLOL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100002-7511-01 J1815 INJECTION, INSULIN HUMALOG MIX 75-25 VIAL 9/1/2010 99/99/9999 E0100002-7512-01 J1815 INJECTION, INSULIN HUMALOG MIX 50-50 VIAL 9/1/2010 99/99/9999 E0100002-7516-59 J1815 INJECTION, INSULIN HUMALOG 100 UNITS/ML CARTRIDGE 9/1/2010 99/99/9999 E0100002-8215-01 J1815 INJECTION, INSULIN HUMULIN R 100 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100002-8315-01 J1815 INJECTION, INSULIN HUMULIN N 100 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100002-8501-01 J1815 INJECTION, INSULIN HUMULIN R 500 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100002-8715-01 J1815 INJECTION, INSULIN HUMULIN 70-30 VIAL 9/1/2010 99/99/9999 E0100002-8725-59 J1815 INJECTION, INSULIN HUMALOG 100 UNITS/ML PEN 9/1/2010 8/1/2013 E0100002-8730-59 J1815 INJECTION, INSULIN HUMULIN N 100 UNITS/ML PEN 9/1/2010 10/31/2015 E0100002-8770-59 J1815 INJECTION, INSULIN HUMULIN 70-30 PEN 9/1/2010 10/31/2015 E0100002-8793-59 J1815 INJECTION, INSULIN HUMALOG MIX 50-50 PEN 9/1/2010 9/30/2011 E0100002-8794-59 J1815 INJECTION, INSULIN HUMALOG MIX 75-25 PEN 9/1/2010 7/1/2012 E0100088-2220-33 J1815 INJECTION, INSULIN LANTUS 100 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100088-2220-52 J1815 INJECTION, INSULIN LANTUS 100 UNITS/ML CARTRIDGE 9/1/2010 6/30/2013 E0100088-2220-60 J1815 INJECTION, INSULIN LANTUS SOLOSTAR 100 UNITS/ML 9/1/2010 99/99/9999 E0100088-2500-52 J1815 INJECTION, INSULIN APIDRA 100 UNITS/ML CARTRIDGE 9/1/2010 9/30/2011 E0100169-1833-11 J1815 INJECTION, INSULIN NOVOLIN R 100 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100169-1833-17 J1815 INJECTION, INSULIN NOVOLIN R 100 UNITS/ML CART 9/1/2010 9/30/2013 E0100169-1834-11 J1815 INJECTION, INSULIN NOVOLIN N 100 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100169-1834-17 J1815 INJECTION, INSULIN NOVOLIN N 100 UNITS/ML CART 9/1/2010 9/30/2013 E0100169-1837-11 J1815 INJECTION, INSULIN NOVOLIN 70-30 100 UNIT/ML VIAL 9/1/2010 99/99/9999 E0100169-1837-17 J1815 INJECTION, INSULIN NOVOLIN 70/30 U100 CARTRIDG 9/1/2010 3/31/2013 E0100169-2313-21 J1815 INJECTION, INSULIN NOVOLIN R 100 UNIT/ML INNOLET 9/1/2010 7/31/2011 E0100169-2314-21 J1815 INJECTION, INSULIN NOVOLIN N 100 UNIT/ML INNOLET 9/1/2010 11/30/2011 E0100169-2317-21 J1815 INJECTION, INSULIN NOVOLIN 70-30 INNOLET 9/1/2010 12/31/2011 E0100169-3303-12 J1815 INJECTION, INSULIN NOVOLOG 100 UNIT/ML CARTRIDGE 9/1/2010 99/99/9999 E0100169-3473-18 J1815 INJECTION, INSULIN NOVOLIN R 100 UNIT/ML CARTRIDG 9/1/2010 7/31/2011 E0100169-3474-18 J1815 INJECTION, INSULIN NOVOLIN N 100 UNIT/ML CARTRIDG 9/1/2010 9/30/2011 E0100169-3477-18 J1815 INJECTION, INSULIN NOVOLIN 70-30 U100 CARTRIDGE 9/1/2010 7/31/2011 E0100169-3685-12 J1815 INJECTION, INSULIN NOVOLOG MIX 70-30 VIAL 9/1/2010 99/99/9999 E0100169-3696-19 J1815 INJECTION, INSULIN NOVOLOG MIX 70-30 FLEXPEN SYRN 9/1/2010 99/99/9999 E0100169-6339-10 J1815 INJECTION, INSULIN NOVOLOG FLEXPEN SYRINGE 9/1/2010 99/99/9999 E0100002-7510-01 J1817 INSULIN ADMIN THROUGH DME HUMALOG 100 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100088-2500-33 J1817 INSULIN ADMIN THROUGH DME APIDRA 100 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100169-7501-11 J1817 INSULIN ADMIN THROUGH DME NOVOLOG 100 UNIT/ML VIAL 9/1/2010 99/99/9999 E0159627-0002-05 J1825 INJECTION, INTERFERON BETA-1A AVONEX PREFILLED SYR 30 MCG KT 9/1/2010 99/99/9999 E0150419-0523-25 J1830 INTERFERON BETA-1B BETASERON 0.3 MG KIT 9/1/2010 12/31/2010 E0151552-0913-01 J1840 INJECTION, KANAMYCIN SULFATE, UP TO 500 KANAMYCIN SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0913-02 J1840 INJECTION, KANAMYCIN SULFATE, UP TO 500 KANAMYCIN SULFATE POWDER 9/1/2010 3/31/2011 E0163323-0359-03 J1840 INJECTION, KANAMYCIN SULFATE, UP TO 500 KANAMYCIN 1 GM/3 ML VIAL 9/1/2010 99/99/9999 E0110019-0030-12 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 5/31/2013 E0100409-2287-21 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML ISECURE SYR 9/1/2010 4/1/2012 E0100409-2287-22 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2ML ISECURE 9/1/2010 10/1/2011 E0100409-2287-31 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML CARPUJECT 9/1/2010 99/99/9999 E0100409-2287-61 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML CARPUJECT 9/1/2010 99/99/9999 E0100409-2288-21 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML ISECURE SYR 9/1/2010 12/31/2012 E0100409-2288-31 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML CARPUJECT 9/1/2010 99/99/9999 E0100409-3793-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-3793-49 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-3795-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-3795-49 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-3795-61 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-3796-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-3796-49 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-3796-61 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 7/1/2011 E0110019-0029-02 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML VIAL 9/1/2010 10/31/2013 E0110019-0030-03 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 5/31/2013 E0110019-0030-04 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 8/31/2013 E0155390-0480-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML VIAL 9/1/2010 3/31/2013 E0155390-0481-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 11/30/2013 E0155390-0481-02 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 3/31/2013 E0155390-0481-10 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 300 MG/10 ML VIAL 9/1/2010 3/31/2014 E0163323-0161-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0162-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0162-02 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 99/99/9999 E0164679-0757-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML VIAL 9/1/2010 3/31/2015 E0164679-0757-02 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 15 MG/ML VIAL 9/1/2010 3/31/2015 E0164679-0758-01 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 4/30/2015 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

64679-0758-02 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 2/28/2015 E0164679-0758-04 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 30 MG/ML VIAL 9/1/2010 3/31/2015 E0164679-0758-06 J1885 INJECTION, KETOROLAC TROMETHAMINE, KETOROLAC 60 MG/2 ML VIAL 9/1/2010 2/28/2015 E0100003-0293-05 J1885 INJECTION, KETOROLAC TROMETHAMINE, KENALOG-40 40 MG/ML VIAL 9/1/2010 99/99/9999 E0158468-0070-01 J1931 INJECTION LARONIDASE, 0.1 MG ALDURAZYME 2.9 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100409-1639-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 10 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-6102-02 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 20 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-6102-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 40 MG/4 ML VIAL 9/1/2010 99/99/9999 E0100409-6102-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 100 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100409-9631-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 10 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100517-5702-25 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 20 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100517-5704-25 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 40 MG/4 ML VIAL 9/1/2010 99/99/9999 E0100517-5710-25 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 100 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0280-02 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 20 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0280-04 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 40 MG/4 ML VIAL 9/1/2010 99/99/9999 E0163323-0280-10 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG FUROSEMIDE 100 MG/10 ML VIAL 9/1/2010 99/99/9999 E0150419-0150-57 J1945 INJECTION, LEPIRUDIN, 50 MG REFLUDAN 50 MG VIAL 9/1/2010 6/20/2014 E0100300-3641-01 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 3.75 MG KIT 9/1/2010 8/1/2011 E0100074-3663-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 11.25 MG 3MO KIT 5/25/2011 99/99/9999 E0100074-3346-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 22.5 MG 3MO KIT 9/1/2010 99/99/9999 E0100074-3641-03 J1950 LUPRON DEPOT 3.75MG. LUPRON DEPOT 3.75 MG KIT 9/1/2010 99/99/9999 E0150474-0002-63 J1953 INJECTION, LEVETIRACETAM, 10 MG KEPPRA 500 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100517-1045-25 J1955 INJECTION, LEVOCARNITINE, PER 1 GM LEVOCARNITINE 200 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-0404-02 J1955 INJECTION, LEVOCARNITINE, PER 1 GM LEVOCARNITINE 200 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-0405-02 J1955 INJECTION, LEVOCARNITINE, PER 1 GM LEVOCARNITINE 200 MG/ML VIAL 9/1/2010 99/99/9999 E0154482-0147-01 J1955 INJECTION, LEVOCARNITINE, PER 1 GM CARNITOR 1 GM/5 ML VIAL 9/1/2010 99/99/9999 E0155390-0136-05 J1955 INJECTION, LEVOCARNITINE, PER 1 GM LEVOCARNITINE 200 MG/ML VIAL 9/1/2010 3/31/2015 E0100045-0065-55 J1956 LEVOFLOXACIN LEVAQUIN I.V. 25 MG/ML VIAL 9/1/2010 12/31/2010 E0100045-0066-01 J1956 LEVOFLOXACIN LEVAQUIN 750 MG/150 ML D5W 9/1/2010 12/31/2011 E0100045-0067-01 J1956 LEVOFLOXACIN LEVAQUIN 250 MG/50 ML D5W 9/1/2010 12/31/2011 E0100045-0068-01 J1956 LEVOFLOXACIN LEVAQUIN 500 MG/100 ML D5W 9/1/2010 12/31/2011 E0100045-0069-51 J1956 LEVOFLOXACIN LEVAQUIN I.V. 25 MG/ML VIAL 9/1/2010 9/30/2010 E0100045-1515-01 J1956 LEVOFLOXACIN LEVAQUIN 25 MG/ML SOLUTION 9/1/2010 2/28/2011 E0100091-1536-05 J1980 INJECTION, HYOSCYAMINE SULFATE LEVSIN 0.5 MG/ML AMPUL 9/1/2010 9/30/2011 E0151552-0141-02 J1980 INJECTION, HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0141-04 J1980 INJECTION, HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE POWDER 9/1/2010 3/31/2011 E0100186-0110-01 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 1% VIAL 9/1/2010 5/31/2013 E0100186-0112-01 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 1% VIAL 9/1/2010 12/31/2012 E0100186-0112-91 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 1% VIAL 9/1/2010 1/31/2013 E0100186-0120-01 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 2% VIAL 9/1/2010 10/31/2012 E0100186-0135-01 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 0.5% VIAL 9/1/2010 12/31/2012 E0100186-0137-01 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 0.5% VIAL 9/1/2010 3/31/2013 E0100186-0145-01 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 1% VIAL 9/1/2010 5/31/2013 E0100186-0155-01 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 2% VIAL 9/1/2010 5/31/2013 E0100186-0210-03 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 1% AMPUL 9/1/2010 2/28/2013 E0100186-0215-03 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 2% AMPUL 9/1/2010 6/30/2012 E0100186-0230-03 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 1% AMPUL 9/1/2010 3/31/2013 E0100186-0232-03 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE IV 2% AMPUL 9/1/2010 10/31/2012 E0100186-0235-03 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 4% AMPUL 9/1/2010 3/31/2013 E0100186-0241-13 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 2% VIAL 9/1/2010 6/30/2013 E0100186-0242-13 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 2% VIAL 9/1/2010 5/31/2013 E0100186-0243-12 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 2% VIAL 9/1/2010 10/31/2012 E0100186-0255-02 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 1% AMPUL 9/1/2010 9/30/2011 E0100186-0275-12 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE 1% VIAL 9/1/2010 9/30/2012 E0100186-0276-13 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 1% VIAL 9/1/2010 5/31/2013 E0100186-0277-13 J2001 LIDOCAINE HCI, INJECTION XYLOCAINE-MPF 1% VIAL 9/1/2010 6/30/2013 E0100264-9594-10 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 9/1/2010 99/99/9999 E0100264-9594-20 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 9/1/2010 99/99/9999 E0100264-9598-10 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 9/1/2010 9/30/2011 E0100264-9598-20 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 9/1/2010 99/99/9999 E0100338-0409-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 9/1/2010 5/31/2012 E0100338-0409-03 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 9/1/2010 99/99/9999 E0100338-0411-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 9/1/2010 99/99/9999 E0100409-1323-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% SYRINGE 9/1/2010 99/99/9999 E0100409-2066-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 9/1/2010 99/99/9999 E0100409-4056-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1.5% AMPUL 9/1/2010 99/99/9999 E0100409-4270-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 9/1/2010 99/99/9999 E0100409-4275-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 0.5% VIAL 9/1/2010 99/99/9999 E0100409-4276-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 9/1/2010 99/99/9999 E0100409-4276-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 9/1/2010 99/99/9999 E0100409-4277-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00409-4277-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 9/1/2010 99/99/9999 E0100409-4278-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 0.5% VIAL 9/1/2010 99/99/9999 E0100409-4279-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 9/1/2010 99/99/9999 E0100409-4282-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% AMPUL 9/1/2010 99/99/9999 E0100409-4282-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% AMPUL 9/1/2010 99/99/9999 E0100409-4283-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 4% AMPUL 9/1/2010 99/99/9999 E0100409-4713-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% AMPUL 9/1/2010 99/99/9999 E0100409-4713-32 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% AMPUL 9/1/2010 99/99/9999 E0100409-4776-01 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1.5% AMPUL 9/1/2010 99/99/9999 E0100409-4903-34 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% ABBOJECT 9/1/2010 99/99/9999 E0100409-4904-34 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% ABBOJECT 9/1/2010 99/99/9999 E0100409-7931-24 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 9/1/2010 99/99/9999 E0100409-7931-32 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.4% IN D5W SOLN 9/1/2010 99/99/9999 E0100409-7939-32 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE 0.8% IN D5W SOLN 9/1/2010 99/99/9999 E0100409-9137-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% SYRINGE 9/1/2010 99/99/9999 E0100517-0625-25 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 9/1/2010 9/30/2012 E0100517-0626-25 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 9/1/2010 7/31/2012 E0100548-1078-00 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% SYRINGE 9/1/2010 3/31/2011 E0100548-1079-00 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% SYRINGE 9/1/2010 3/31/2011 E0100548-1080-00 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% SYRINGE 9/1/2010 3/31/2011 E0100548-1081-00 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% SYRINGE 9/1/2010 3/31/2011 E0100548-1190-00 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% SYRINGE 9/1/2010 3/31/2011 E0100548-2190-00 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% MIN-I-JET 9/1/2010 3/31/2011 E0100548-3390-00 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% LUER-JET 9/1/2010 9/30/2014 E0151552-0106-04 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0106-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0106-06 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0106-09 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL POWDER 9/1/2010 3/31/2011 E0163323-0201-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 9/1/2010 99/99/9999 E0163323-0201-10 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 1% VIAL 9/1/2010 99/99/9999 E0163323-0202-02 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 9/1/2010 99/99/9999 E0163323-0208-05 J2001 LIDOCAINE HCI, INJECTION LIDOCAINE HCL 2% VIAL 9/1/2010 99/99/9999 E0100009-0555-01 J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG LINCOCIN 300 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0555-02 J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG LINCOCIN 300 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-5137-01 J2020 INJECTION, LINEZOLID, 200MG ZYVOX 200 MG/100 ML IV SOLN 9/1/2010 99/99/9999 E0100009-5140-01 J2020 INJECTION, LINEZOLID, 200MG ZYVOX 600 MG/300 ML IV SOLN 9/1/2010 99/99/9999 E0100409-1539-31 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 4 MG/ML CARPUJECT 9/1/2010 99/99/9999 E0100409-1985-30 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML CARPUJECT 9/1/2010 99/99/9999 E0100409-6778-02 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-6778-62 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-6779-02 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 4 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-6780-02 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-6781-02 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 4 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0102-01 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 2/28/2014 E0110019-0102-10 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 8/31/2013 E0110019-0102-39 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 2/28/2014 E0110019-0103-01 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 4 MG/ML VIAL 9/1/2010 1/31/2014 E0110019-0103-10 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 4 MG/ML VIAL 9/1/2010 12/31/2013 E0110019-0105-01 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 2 MG/ML VIAL 9/1/2010 11/30/2013 E0110019-0105-02 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 20 MG/10 ML VIAL 9/1/2010 9/30/2013 E0110019-0105-44 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 2 MG/ML VIAL 9/1/2010 11/30/2013 E0110019-0105-71 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 20 MG/10 ML VIAL 9/1/2010 9/30/2013 E0110019-0106-01 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 4 MG/ML VIAL 9/1/2010 1/31/2014 E0110019-0106-02 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 4 MG/ML VIAL 9/1/2010 12/31/2013 E0110019-0106-44 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 4 MG/ML VIAL 9/1/2010 1/31/2014 E0110019-0106-71 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 4 MG/ML VIAL 9/1/2010 12/31/2013 E0117478-0040-01 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 99/99/9999 E0155390-0168-10 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0169-10 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 4 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0170-10 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 2 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0171-10 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) LORAZEPAM 4 MG/ML VIAL 9/1/2010 9/30/2011 E0160977-0112-01 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 2 MG/ML VIAL 9/1/2010 2/28/2014 E0160977-0113-01 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 4 MG/ML VIAL 9/1/2010 1/31/2014 E0160977-0113-02 J2060 INJECTION, LORAZEPAM, 2MG (ATIVAN) ATIVAN 4 MG/ML VIAL 9/1/2010 12/31/2013 E0100409-4031-01 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL 25% VIAL 9/1/2010 99/99/9999 E0100517-4050-25 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL 25% VIAL 9/1/2010 99/99/9999 E0151552-0380-05 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL POWDER 9/1/2010 3/31/2011 E0163323-0024-25 J2150 INJECTION, MANNITOL, 25% IN 50 ML MANNITOL 25% VIAL 9/1/2010 99/99/9999 E0115054-1040-05 J2170 INJECTION, MECASERMIN, 1 MG INCRELEX 40 MG/4 ML VIAL 9/1/2010 99/99/9999 E0100338-2691-75 J2175 INJECTION, MEPERIDINE 50 MG MEPERIDINE 10 MG/ML SYRINGE 9/1/2010 9/30/2010 E0100406-1585-55 J2175 INJECTION, MEPERIDINE 50 MG MEPERIDINE HCL POWDER 9/1/2010 12/31/2010 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00409-1176-30 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 25 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-1178-30 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 50 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-1179-30 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 75 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-1180-69 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 100 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-1181-30 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1201-20 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 100 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1203-01 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-1253-01 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-1254-01 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 75 MG/1.5 ML AMPUL 9/1/2010 99/99/9999 E0100409-1255-02 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-1256-01 J2175 INJECTION, MEPERIDINE 50 MG DEMEROL 100 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-6030-04 J2175 INJECTION, MEPERIDINE 50 MG MEPERIDINE 10 MG/ML CARTRDGE 9/1/2010 99/99/9999 E0110019-0159-01 J2175 INJECTION, MEPERIDINE 50 MG MEPERIDINE 25 MG/ML VIAL 9/1/2010 2/28/2013 E0110019-0160-01 J2175 INJECTION, MEPERIDINE 50 MG MEPERIDINE 50 MG/ML VIAL 9/1/2010 4/30/2013 E0110019-0160-44 J2175 INJECTION, MEPERIDINE 50 MG MEPERIDINE 50 MG/ML VIAL 9/1/2010 4/30/2013 E0110019-0162-01 J2175 INJECTION, MEPERIDINE 50 MG MEPERIDINE 100 MG/ML VIAL 9/1/2010 3/31/2013 E0100310-0321-30 J2185 INJECTION, MEROPENEM, 100 MG MERREM IV 1 GM VIAL 9/1/2010 99/99/9999 E0100310-0321-65 J2185 INJECTION, MEROPENEM, 100 MG MERREM IV 1 GM VIAL 9/1/2010 2/18/2015 E0100310-0325-20 J2185 INJECTION, MEROPENEM, 100 MG MERREM IV 500 MG VIAL 9/1/2010 99/99/9999 E0100310-0325-64 J2185 INJECTION, MEROPENEM, 100 MG MERREM IV 500 MG VIAL 9/1/2010 1/31/2014 E0100078-0053-03 J2210 INJECTION, METHYLERGONOVINE MALEATE, UP METHERGINE 0.2 MG/ML AMPUL 9/1/2010 3/31/2015 E0100469-3211-10 J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG MYCAMINE 100 MG VIAL 9/1/2010 99/99/9999 E0100469-3250-10 J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG MYCAMINE 50 MG VIAL 9/1/2010 99/99/9999 E0100409-2305-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 5/1/2012 E0100409-2305-05 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2305-49 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 5/1/2012 E0100409-2305-50 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2305-61 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 7/1/2011 E0100409-2305-62 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 8/1/2011 E0100409-2306-22 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM 2 MG/2 ML ISECURE 9/1/2010 12/31/2011 E0100409-2306-62 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM 2 MG/2 ML CARPUJECT 9/1/2010 99/99/9999 E0100409-2307-21 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM 5 MG/ML ISECURE SYR 9/1/2010 6/1/2012 E0100409-2307-60 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM 5 MG/ML CARPUJECT 9/1/2010 99/99/9999 E0100409-2308-01 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2308-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2308-49 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2308-50 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2587-05 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 10 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100409-2587-53 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 10 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100409-2596-03 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2596-05 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2596-52 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2596-53 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0027-01 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 3/28/2011 E0110019-0027-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 12/31/2010 E0110019-0027-03 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 3/28/2011 E0110019-0027-04 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 12/31/2010 E0110019-0027-10 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 5/31/2013 E0110019-0027-36 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 12/31/2010 E0110019-0028-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 3/31/2011 E0110019-0028-03 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 3/31/2011 E0110019-0028-05 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/5 ML VIAL 9/1/2010 10/31/2013 E0110019-0028-10 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 10 MG/10 ML VIAL 9/1/2010 10/31/2013 E0155390-0125-10 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 10 MG/10 ML VIAL 9/1/2010 1/31/2013 E0155390-0126-05 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 5/31/2013 E0155390-0126-10 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 6/30/2014 E0155390-0137-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 3/31/2013 E0155390-0137-05 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 6/30/2013 E0155390-0138-01 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 6/30/2013 E0155390-0138-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 3/31/2014 E0163323-0411-10 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 10 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0411-12 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 2 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0411-25 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/5 ML VIAL 9/1/2010 99/99/9999 E0163323-0412-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 10 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0412-05 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0412-10 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0412-25 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 99/99/9999 E0166758-0018-01 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 3/31/2011 E0166758-0018-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 1 MG/ML VIAL 9/1/2010 3/31/2011 E0166758-0019-01 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 9/30/2011 E0166758-0019-02 J2250 INJECTION, MIDAZOLAM HCL, PER 1MG MIDAZOLAM HCL 5 MG/ML VIAL 9/1/2010 9/30/2011 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00024-1200-06 J2260 INJECTION, MILRINONE LACTATE, 5MG PRIMACOR 1 MG/ML CARPUJECT 9/1/2010 3/31/2011 E0100338-6010-48 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE-D5W 20 MG/100 ML 9/1/2010 99/99/9999 E0100338-6011-37 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE-D5W 40 MG/200 ML 9/1/2010 99/99/9999 E0100409-2776-02 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE-D5W 40 MG/200 ML 9/1/2010 99/99/9999 E0100409-2776-23 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE-D5W 20 MG/100 ML 9/1/2010 99/99/9999 E0110019-0070-01 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 10 MG/10 ML VL 9/1/2010 6/30/2013 E0110019-0070-02 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 20 MG/20 ML VL 9/1/2010 6/30/2013 E0155390-0019-10 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 10 MG/10 ML VL 9/1/2010 3/31/2014 E0155390-0020-10 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 20 MG/20 ML VL 9/1/2010 3/31/2014 E0155390-0021-01 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 50 MG/50 ML VL 9/1/2010 5/31/2015 E0155390-0074-10 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 10 MG/10 ML VL 9/1/2010 3/31/2013 E0155390-0075-10 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 20 MG/20 ML VL 9/1/2010 2/29/2012 E0155390-0076-01 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 50 MG/50 ML VL 9/1/2010 2/29/2012 E0160505-0718-00 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 10 MG/10 ML VL 9/1/2010 99/99/9999 E0160505-0718-01 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 20 MG/20 ML VL 9/1/2010 99/99/9999 E0163323-0617-10 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 10 MG/10 ML VL 9/1/2010 99/99/9999 E0163323-0617-20 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 20 MG/20 ML VL 9/1/2010 99/99/9999 E0163323-0617-50 J2260 INJECTION, MILRINONE LACTATE, 5MG MILRINONE LACT 50 MG/50 ML VL 9/1/2010 99/99/9999 E0100338-2689-75 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML SYRINGE 9/1/2010 9/30/2010 E0100409-1258-30 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 4 MG/ML SYRINGE 9/1/2010 9/1/2013 E0100409-1260-69 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 8 MG/ML SYRINGE 9/1/2010 10/1/2013 E0100409-1261-30 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 10 MG/ML SYRINGE 9/1/2010 3/1/2014 E0100409-1762-30 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 2 MG/ML SYRINGE 9/1/2010 11/1/2013 E0100409-3815-12 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML VIAL P-F 9/1/2010 99/99/9999 E0100409-4058-12 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML AMPUL P-F 9/1/2010 8/1/2011 E0100409-6062-02 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML-D5W 250 ML 9/1/2010 7/1/2011 E0100409-6062-11 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML-D5W 100 ML 9/1/2010 9/30/2011 E0100409-6177-14 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE SULFATE 25 MG/ML VL 9/1/2010 99/99/9999 E0100409-6179-14 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE SULFATE 25 MG/ML VL 9/1/2010 99/99/9999 E0100548-1911-25 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML SYRINGE 9/1/2010 8/31/2015 E0100548-1931-10 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-2901-25 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 1 MG/ML SYRINGE 9/1/2010 10/31/2010 E0100548-6045-25 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 25 MG/ML SYRINGE 9/1/2010 3/31/2011 E0110019-0176-44 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 5 MG/ML VIAL 9/1/2010 10/31/2013 E0110019-0177-44 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 8 MG/ML VIAL 9/1/2010 1/31/2013 E0110019-0177-68 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 8 MG/ML AMPULE 9/1/2010 12/31/2011 E0110019-0178-44 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 10 MG/ML VIAL 9/1/2010 11/30/2013 E0110019-0178-62 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 10 MG/ML VIAL 9/1/2010 7/31/2013 E0110019-0178-68 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG MORPHINE 10 MG/ML AMPUL 9/1/2010 12/31/2011 E0100406-1521-53 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE POWDER 9/1/2010 3/31/2011 E0100406-1521-55 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE POWDER 9/1/2010 3/31/2011 E0100406-1521-56 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE POWDER 9/1/2010 3/31/2011 E0100406-1521-57 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE POWDER 9/1/2010 3/31/2011 E0100409-1134-03 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1134-05 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1264-31 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE 15 MG/ML SYRINGE 9/1/2010 6/1/2013 E0100409-6028-04 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100574-2006-25 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE POWDER 9/1/2010 12/31/2010 E0110019-0179-44 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE 15 MG/ML VIAL 9/1/2010 1/31/2013 E0110019-0179-63 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE 15 MG/ML VIAL 9/1/2010 10/31/2013 E0151552-0678-04 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0678-06 J2271 INJECTION, MORPHINE SULFATE, 100 MG MORPHINE SULFATE POWDER 9/1/2010 3/31/2011 E0100186-1150-02 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV ASTRAMORPH-PF 0.5 MG/ML AMP 9/1/2010 2/28/2012 E0100186-1151-02 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV ASTRAMORPH-PF 1 MG/ML AMPUL 9/1/2010 3/31/2012 E0100186-1152-12 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV ASTRAMORPH-PF 0.5 MG/ML VIAL 9/1/2010 8/31/2011 E0100186-1153-12 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV ASTRAMORPH-PF 1 MG/ML VIAL 9/1/2010 9/30/2011 E0100186-1159-03 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV ASTRAMORPH-PF 0.5 MG/ML AMP 9/1/2010 11/30/2011 E0100186-1160-03 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV ASTRAMORPH-PF 1 MG/ML AMPUL 9/1/2010 4/30/2012 E0100409-1135-02 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV MORPHINE SULFATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-3814-12 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV MORPHINE 0.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-4057-12 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV MORPHINE 0.5 MG/ML AMPUL P-F 9/1/2010 12/31/2011 E0100555-1127-10 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV MORPHINE 0.5 MG/ML AMPUL P-F 9/1/2010 6/30/2011 E0100555-1128-10 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV MORPHINE 1 MG/ML AMPUL P-F 9/1/2010 3/31/2011 E0100555-1129-10 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV MORPHINE 0.5 MG/ML VIAL 9/1/2010 10/31/2010 E0100555-1130-10 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV MORPHINE 1 MG/ML VIAL 9/1/2010 10/31/2010 E0160977-0016-02 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV DURAMORPH 0.5 MG/ML AMPUL 9/1/2010 2/28/2015 E0160977-0017-01 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV DURAMORPH 1 MG/ML AMPUL 9/1/2010 2/28/2015 E0160977-0114-01 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV INFUMORPH 10 MG/ML AMPUL P-F 9/1/2010 10/31/2014 E0160977-0115-01 J2275 INJECTION, MORPHINE SULFATE (PRESERVATIV INFUMORPH 25 MG/ML AMPUL P-F 9/1/2010 9/30/2014 E0159075-0720-10 J2278 INJECTION, ZICONOTIDE, 1 MCG PRIALT 100 MCG/ML VIAL 9/1/2010 4/1/2013 E0159075-0722-10 J2278 INJECTION, ZICONOTIDE, 1 MCG PRIALT 100 MCG/ML VIAL 9/1/2010 4/1/2013 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

59075-0723-10 J2278 INJECTION, ZICONOTIDE, 1 MCG PRIALT 25 MCG/ML VIAL 9/1/2010 12/31/2011 E0100085-1737-01 J2280 INJECTION, MOXIFLOXACIN, 100 MG AVELOX IV 400 MG/250 ML 9/1/2010 99/99/9999 E0100409-1463-01 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 10 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-1464-01 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 100 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100409-1465-01 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 20 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-1467-01 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 200 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100555-1119-09 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 100 MG/10 ML VIAL 9/1/2010 3/31/2011 E0100555-1120-09 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 200 MG/10 ML VIAL 9/1/2010 11/30/2010 E0100555-1121-05 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 10 MG/ML AMPUL 9/1/2010 3/31/2011 E0100555-1122-05 J2300 INJECTION, NALBUPHINE HCL, PER 10MG NALBUPHINE 20 MG/ML AMPUL 9/1/2010 2/28/2011 E0100406-1492-52 J2310 INJECTION, NALOXONE HCL, PER 1 MG NALOXONE HCL POWDER 9/1/2010 3/31/2011 E0100409-1212-01 J2310 INJECTION, NALOXONE HCL, PER 1 MG NALOXONE 0.4 MG/ML AMPUL 9/1/2010 12/31/2011 E0100409-1215-01 J2310 INJECTION, NALOXONE HCL, PER 1 MG NALOXONE 0.4 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1219-01 J2310 INJECTION, NALOXONE HCL, PER 1 MG NALOXONE 0.4 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1782-69 J2310 INJECTION, NALOXONE HCL, PER 1 MG NALOXONE 0.4 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100548-1469-00 J2310 INJECTION, NALOXONE HCL, PER 1 MG NALOXONE 1 MG/ML SYRINGE 9/1/2010 1/31/2014 E0100548-3369-00 J2310 INJECTION, NALOXONE HCL, PER 1 MG NALOXONE 1 MG/ML SYRINGE 9/1/2010 2/28/2014 E0165757-0300-01 J2315 INJECTION, NALTREXONE, DEPOT FORM, 1 MG VIVITROL 380 MG VIAL + DILUENT 9/1/2010 99/99/9999 E0151552-1043-02 J2321 INJECTION, NANDROLONE DECANOATE, UP TO 1 NANDROLONE DECANOATE POWDER 9/1/2010 3/31/2011 E0159075-0730-15 J2323 INJECTION, NATALIZUMAB, 1 MG TYSABRI 300 MG/15 ML VIAL 9/1/2010 10/31/2016 E0165847-0205-25 J2325 INJECTION, NESIRITIDE, 0.1 MG NATRECOR 1.5 MG VIAL 9/1/2010 99/99/9999 E0100078-0340-61 J2353 INJECTION, OCTREOTIDE, DEPOT FORM FOR IN SANDOSTATIN LAR 10 MG KIT 9/1/2010 99/99/9999 E0100078-0341-61 J2353 INJECTION, OCTREOTIDE, DEPOT FORM FOR IN SANDOSTATIN LAR 20 MG KIT 9/1/2010 99/99/9999 E0100078-0342-61 J2353 INJECTION, OCTREOTIDE, DEPOT FORM FOR IN SANDOSTATIN LAR 30 MG KIT 9/1/2010 99/99/9999 E0100078-0180-01 J2354 INJECTION, OCTREOTIDE SANDOSTATIN 0.05 MG/ML AMPUL 9/1/2010 99/99/9999 E0100078-0181-01 J2354 INJECTION, OCTREOTIDE SANDOSTATIN 0.1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100078-0182-01 J2354 INJECTION, OCTREOTIDE SANDOSTATIN 0.5 MG/ML AMPUL 9/1/2010 99/99/9999 E0100078-0183-25 J2354 INJECTION, OCTREOTIDE SANDOSTATIN 0.2 MG/ML VIAL 9/1/2010 99/99/9999 E0100078-0184-25 J2354 INJECTION, OCTREOTIDE SANDOSTATIN 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-3301-04 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 50 MCG/ML VIAL 9/1/2010 99/99/9999 E0100703-3311-04 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 100 MCG/ML VL 9/1/2010 99/99/9999 E0100703-3321-04 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 500 MCG/ML VL 9/1/2010 99/99/9999 E0100703-3333-01 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 200 MCG/ML VL 9/1/2010 99/99/9999 E0100703-3343-01 J2354 INJECTION, OCTREOTIDE OCTREOTIDE 1,000 MCG/ML VIAL 9/1/2010 99/99/9999 E0100781-9164-75 J2354 INJECTION, OCTREOTIDE OCTREOTIDE 1,000 MCG/ML VIAL 9/1/2010 6/29/2014 E0100781-9165-75 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 200 MCG/ML VL 9/1/2010 11/17/2014 E0100781-9166-95 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 50 MCG/ML AMP 9/1/2010 99/99/9999 E0100781-9167-95 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 100 MCG/ML AMP 9/1/2010 99/99/9999 E0100781-9168-95 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 500 MCG/ML AMP 9/1/2010 99/99/9999 E0155390-0160-10 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 50 MCG/ML VIAL 9/1/2010 2/28/2013 E0155390-0161-10 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 100 MCG/ML VL 9/1/2010 4/30/2013 E0155390-0162-10 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 500 MCG/ML VL 9/1/2010 3/31/2015 E0155390-0163-01 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 200 MCG/ML VL 9/1/2010 12/31/2014 E0155390-0164-01 J2354 INJECTION, OCTREOTIDE OCTREOTIDE 1,000 MCG/ML VIAL 9/1/2010 12/31/2014 E0163323-0365-01 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 50 MCG/ML VIAL 9/1/2010 99/99/9999 E0163323-0376-01 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 100 MCG/ML VL 9/1/2010 99/99/9999 E0163323-0377-01 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 500 MCG/ML VL 9/1/2010 99/99/9999 E0163323-0378-05 J2354 INJECTION, OCTREOTIDE OCTREOTIDE ACET 200 MCG/ML VL 9/1/2010 99/99/9999 E0163323-0379-05 J2354 INJECTION, OCTREOTIDE OCTREOTIDE 1,000 MCG/ML VIAL 9/1/2010 99/99/9999 E0150242-0040-62 J2357 INJECTION, OMALIZOMAB, 5 MG XOLAIR 150 MG VIAL 9/1/2010 99/99/9999 E0100591-3222-47 J2360 INJECTION, ORPHENADRINE CITRATE ORPHENADRINE 30 MG/ML AMPULE 9/1/2010 99/99/9999 E0117478-0538-02 J2360 INJECTION, ORPHENADRINE CITRATE ORPHENADRINE 30 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0839-05 J2360 INJECTION, ORPHENADRINE CITRATE ORPHENADRINE CITRATE POWDER 9/1/2010 3/31/2011 E0155390-0059-10 J2360 INJECTION, ORPHENADRINE CITRATE ORPHENADRINE 30 MG/ML VIAL 9/1/2010 3/31/2014 E0100074-1800-01 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML NEO-SYNEPHRINE 10 MG/ML AMP 9/1/2010 9/1/2010 E0100409-1800-01 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML NEO-SYNEPHRINE 10 MG/ML AMP 9/1/2010 8/1/2014 E0100517-0299-25 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-0405-25 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0163-01 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 8/30/2011 E0110019-0163-12 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 7/31/2013 E0166758-0016-01 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0166758-0016-02 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 12/31/2010 E0166758-0016-03 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0166758-0016-04 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0166758-0017-01 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML PHENYLEPHRINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100186-0971-66 J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, NESACAINE 1% VIAL 9/1/2010 9/30/2011 E0100186-0972-66 J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, NESACAINE 2% VIAL 9/1/2010 9/30/2011 E0100409-4169-01 J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, CHLOROPROCAINE 2% VIAL 9/1/2010 1/1/2013 E0100409-4170-01 J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, CHLOROPROCAINE 3% VIAL 9/1/2010 7/1/2013 E0155390-0403-20 J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, CHLOROPROCAINE 2% VIAL 9/1/2010 3/31/2014 E0155390-0404-20 J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, CHLOROPROCAINE 3% VIAL 9/1/2010 3/31/2014 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00641-6080-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 8/29/2012 99/99/9999 E0100641-6080-25 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 3/8/2012 99/99/9999 E0123155-0168-31 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 2/15/2013 99/99/9999 E0110019-0905-03 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2013 E0100781-5238-64 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON ODT 4 MG TABLET 9/1/2010 99/99/9999 E0100781-5239-80 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON ODT 8 MG TABLET 9/1/2010 99/99/9999 E0100409-4755-03 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-4755-63 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2011 E0100781-3010-95 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 99/99/9999 E0110019-0905-17 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2013 E0100143-9771-06 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 32 MG/50 ML BG 2/8/2011 99/99/9999 E0100143-9890-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100143-9891-05 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100173-0442-00 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ZOFRAN 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100173-0442-02 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ZOFRAN 4 MG/2 ML VIAL 9/1/2010 3/31/2012 E0100338-1762-41 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 32 MG/50 ML BAG 9/1/2010 10/31/2012 E0100409-1120-62 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML SYR 9/1/2010 3/1/2013 E0100409-4755-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2011 E0100409-4755-02 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2011 E0100409-4759-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100409-4760-13 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 32 MG/50 ML BG 9/1/2010 9/30/2011 E0100703-7221-02 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 6/30/2011 E0100703-7221-04 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100703-7226-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100703-7226-03 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100703-7239-39 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 32 MG/50 ML BG 9/1/2010 12/31/2012 E0100781-3057-14 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 8/31/2011 E0110019-0905-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2013 E0110019-0906-03 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 7/31/2013 E0110019-0906-04 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 12/31/2011 E0155390-0121-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 3/31/2014 E0155390-0121-10 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2011 E0155390-0307-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 9/30/2011 E0155390-0307-10 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 12/31/2010 E0160505-0744-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 99/99/9999 E0160505-0744-06 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 99/99/9999 E0161703-0244-07 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2011 E0161703-0245-22 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 9/30/2011 E0163323-0373-02 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0374-20 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 99/99/9999 E0164679-0726-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 11/30/2014 E0164679-0727-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 3/31/2015 E0100781-3010-72 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 99/99/9999 E0168462-0157-13 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON ODT 4 MG TABLET 9/1/2010 99/99/9999 E0100781-5257-31 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG TABLET 9/1/2010 1/31/2013 E0166860-0088-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON 40 MG/20 ML VIAL 9/1/2010 12/31/2010 E0110019-0905-02 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 9/1/2010 9/30/2013 E0100641-6078-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 11/1/2011 99/99/9999 E0100641-6078-25 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 ONDANSETRON HCL 4 MG/2 ML VIAL 3/8/2012 99/99/9999 E0100409-3795-01 J2405 ODANSETRON HYDROCHLORIDE (ZOFRAN), PER 1 KETOROLAC 30 MG/ML VIAL 9/1/2010 99/99/9999 E0163481-0444-10 J2410 INJECTION, OXYMORPHONE HCL, UP TO 1 MG NUMORPHAN 1 MG/ML AMPUL 9/1/2010 12/31/2010 E0163481-0624-10 J2410 INJECTION, OXYMORPHONE HCL, UP TO 1 MG OPANA 1 MG/ML INJ AMPULE 9/1/2010 99/99/9999 E0155513-0520-01 J2425 INJECTION, PALIFERMIN, 50 MCG KEPIVANCE 6.25 MG VIAL 9/1/2010 12/31/2012 E0155513-0520-06 J2425 INJECTION, PALIFERMIN, 50 MCG KEPIVANCE 6.25 MG VIAL 9/1/2010 12/31/2012 E0140042-0019-10 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 9/1/2010 12/31/2012 E0100078-0463-91 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG AREDIA 30 MG VIAL 9/1/2010 2/29/2012 E0100078-0464-61 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG AREDIA 90 MG VIAL 9/1/2010 9/30/2011 E0100703-4075-19 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIA 9/1/2010 99/99/9999 E0100703-4075-59 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100703-4085-11 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 90 MG/10 ML VIA 9/1/2010 99/99/9999 E0100703-4085-51 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 9/1/2010 99/99/9999 E0155390-0127-01 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 9/1/2010 3/31/2014 E0155390-0129-01 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 9/1/2010 3/31/2014 E0155390-0157-01 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE DISOD 30 MG VIAL 9/1/2010 8/31/2012 E0155390-0159-01 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE DISOD 90 MG VIAL 9/1/2010 8/31/2012 E0155390-0204-01 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 9/1/2010 9/30/2011 E0155390-0604-01 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 9/1/2010 9/30/2011 E0161703-0324-18 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 9/1/2010 99/99/9999 E0161703-0324-39 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 9/1/2010 9/30/2011 E0161703-0325-18 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 60 MG/10 ML VIAL 9/1/2010 99/99/9999 E0161703-0326-18 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

61703-0356-18 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0734-10 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 30 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0734-35 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG OTN PAMIDRONATE 3 MG/ML VIA 9/1/2010 99/99/9999 E0163323-0735-10 J2430 PAMIDRONATE DISODIUM INJECTION PER 30 MG PAMIDRONATE 90 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100517-4002-25 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE 60 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100517-4010-01 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE 300 MG/10 ML VIAL 9/1/2010 99/99/9999 E0151552-0416-02 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0416-04 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0416-05 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0416-07 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE HCL POWDER 9/1/2010 3/31/2011 E0155390-0107-10 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE 30 MG/ML VIAL 9/1/2010 12/31/2010 E0166758-0014-01 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE 30 MG/ML VIAL 9/1/2010 5/31/2011 E0166758-0014-02 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE 60 MG/2 ML VIAL 9/1/2010 5/31/2011 E0166758-0015-01 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG PAPAVERINE 300 MG/10 ML VIAL 9/1/2010 9/30/2011 E0151552-1069-02 J2460 INJECTION, OXYTETRACYCLINE HCL, UP TO 50 OXYTETRACYCLINE HCL POWDER 9/1/2010 3/31/2011 E0158063-0797-25 J2469 INJECTION, PALONOSETRON HCL 25 MG ALOXI 0.25 MG/5 ML VIAL 9/1/2010 9/30/2011 E0100074-1658-01 J2501 INJECTION, PARICALCITOL, 1 MCG ZEMPLAR 5 MCG/ML VIAL 9/1/2010 99/99/9999 E0100074-1658-02 J2501 INJECTION, PARICALCITOL, 1 MCG ZEMPLAR 10 MCG/2 ML VIAL 9/1/2010 7/1/2012 E0100074-4637-01 J2501 INJECTION, PARICALCITOL, 1 MCG ZEMPLAR 2 MCG/ML VIAL 9/1/2010 99/99/9999 E0100074-1658-05 J2501 INJECTION, PARICALCITOL, 1 MCG ZEMPLAR 10 MCG/2 ML VIAL 5/25/2011 99/99/9999 E0168782-0001-02 J2503 INJECTION, PEGAPTANIB SODIUM, 0.3 MG MACUGEN 0.3 MG/90 MICROLITERS 9/1/2010 99/99/9999 E0168782-0001-01 J2503 INJECTION, PEGAPTANIB SODIUM, 0.3 MG MACUGEN 0.3 MG/90 MICROLITERS 9/1/2010 12/31/2012 E0157665-0001-01 J2504 INJECTION, PEGADEMASE BOVINE, 25 IU ADAGEN 250 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0190-01 J2505 INJECTION, PEGFILGRASTIM, 6 MG NEULASTA 6 MG/0.6 ML SYRINGE 9/1/2010 99/99/9999 E0160793-0130-10 J2510 INJECTION, PENICILLIN G PROCAINE, AQUEOU PENICILLIN G 600,000 UNIT/1 ML 9/1/2010 99/99/9999 E0160793-0131-10 J2510 INJECTION, PENICILLIN G PROCAINE, AQUEOU PEN G 1.2 MILLION UNIT/2 ML 9/1/2010 99/99/9999 E0167386-0501-52 J2515 INJECTION, PENTOBARBITAL SODIUM, PER 50 NEMBUTAL SODIUM 50 MG/ML VIA 9/1/2010 8/31/2014 E0167386-0501-55 J2515 INJECTION, PENTOBARBITAL SODIUM, PER 50 NEMBUTAL SODIUM 50 MG/ML VIA 9/1/2010 8/31/2014 E0100049-0520-83 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PFIZERPEN 5 MILLION UNITS VIAL 9/1/2010 99/99/9999 E0100049-0530-28 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PFIZERPEN 20 MILLION UNIT VIAL 9/1/2010 99/99/9999 E0100338-1021-41 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PEN G K 1 MILLION UNIT/50 ML 9/1/2010 99/99/9999 E0100338-1023-41 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PEN G K 2 MILLION UNIT/50 ML 9/1/2010 99/99/9999 E0100338-1025-41 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PEN G K 3 MILLION UNIT/50 ML 9/1/2010 99/99/9999 E0100781-6135-95 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PENICILLIN G K 5 MILLION UNIT 9/1/2010 99/99/9999 E0100781-6136-94 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO PENICILLIN GK 20 MILLION UNIT 9/1/2010 99/99/9999 E0163323-0300-20 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA PIPERACIL-TAZOBACT 3.375 GM VL 8/30/2011 99/99/9999 E0163323-0320-50 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA PIPERACIL-TAZOBACT 4.5 GM VIAL 8/30/2011 99/99/9999 E0125021-0164-30 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA PIPERACIL-TAZOBACT 2.25 GM VL 11/8/2011 99/99/9999 E0125021-0165-30 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA PIPERACIL-TAZOBACT 3.375 GM VL 11/8/2011 99/99/9999 E0100409-3378-13 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA PIPERACIL-TAZOBACT 3.375 GM VL 2/8/2011 99/99/9999 E0100409-3385-13 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA PIPERACIL-TAZOBACT 3.375 GM VL 2/6/2011 99/99/9999 E0100781-3110-95 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA PIPERACIL-TAZOBACT 2.25 GM VL 1/1/2011 99/99/9999 E0100206-8852-16 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 2.25 GRAM VIAL 9/1/2010 99/99/9999 E0100206-8854-16 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 3.375 GRAM VIAL 9/1/2010 99/99/9999 E0100206-8855-16 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 4.5 GRAM VIAL 9/1/2010 99/99/9999 E0100206-8859-10 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 40.5 GRAM BULK VIAL 9/1/2010 99/99/9999 E0100206-8860-02 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 2.25 GM/50 ML GALAXY BAG 9/1/2010 99/99/9999 E0100206-8861-02 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 3.375 GM/50 ML GALAXY 9/1/2010 99/99/9999 E0100206-8862-02 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 4.5 GM/100 ML GALAXY BAG 9/1/2010 99/99/9999 E0100206-2413-02 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 4.5 GM/100 ML GALAXY BAG 8/30/2011 99/99/9999 E0100206-2404-02 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 2.25 GRAM VIAL 8/30/2011 99/99/9999 E0100206-2405-02 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 3.375 GRAM VIAL 9/1/2010 99/99/9999 E0100206-8854-08 J2543 INJECTION, PIPERACILLIN SODIUM/TAZOBACTA ZOSYN 3.375 GRAM VIAL 9/1/2010 99/99/9999 E0100143-9868-22 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100143-9869-22 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 9/1/2010 99/99/9999 E0160977-0001-43 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 9/1/2010 1/31/2014 E0160977-0002-43 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 9/1/2010 4/30/2014 E0139822-5500-05 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 8/16/2012 99/99/9999 E0100641-1496-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-2312-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML SYRINGE 9/1/2010 12/31/2012 E0100641-0928-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0928-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0929-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0929-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0948-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 9/1/2010 99/99/9999 E0100641-0948-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 9/1/2010 99/99/9999 E0100641-0949-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100641-0955-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0956-25 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-1495-31 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 9/1/2010 99/99/9999 E0100641-1495-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML AMPUL 9/1/2010 99/99/9999 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00641-1496-35 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100703-2191-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-2201-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0097-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 6/30/2013 E0110019-0097-44 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 6/30/2013 E0151552-0147-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0147-02 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0147-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0147-05 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE HCL POWDER 9/1/2010 3/31/2011 E0160977-0001-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML AMPUL 9/1/2010 1/31/2014 E0160977-0001-03 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 9/1/2010 4/30/2013 E0160977-0001-44 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 25 MG/ML VIAL 9/1/2010 4/30/2013 E0160977-0002-02 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML AMPUL 9/1/2010 4/30/2014 E0160977-0002-04 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML VIAL 9/1/2010 12/31/2012 E0160977-0002-44 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PHENERGAN 50 MG/ML VIAL 9/1/2010 12/31/2012 E0100703-2191-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-2201-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0956-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0955-21 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG PROMETHAZINE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1253-01 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG DEMEROL 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-2343-31 J2560 INJECTION, PHENOBARBITAL SODIUM, UP TO 1 LUMINAL 60 MG/ML CARPUJECT 9/1/2010 9/30/2011 E0100409-2349-31 J2560 INJECTION, PHENOBARBITAL SODIUM, UP TO 1 LUMINAL 130 MG/ML CARPUJECT 9/1/2010 9/30/2011 E0100641-0476-25 J2560 INJECTION, PHENOBARBITAL SODIUM, UP TO 1 PHENOBARBITAL 65 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-0477-25 J2560 INJECTION, PHENOBARBITAL SODIUM, UP TO 1 PHENOBARBITAL 130 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0291-02 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS OXYTOCIN 10 UNITS/ML VIAL 9/1/2010 2/28/2013 E0110019-0291-04 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS OXYTOCIN 10 UNITS/ML VIAL 9/1/2010 1/31/2013 E0110019-0291-12 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS OXYTOCIN 10 UNITS/ML VIAL 9/1/2010 2/28/2013 E0110019-0291-71 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS OXYTOCIN 10 UNITS/ML VIAL 9/1/2010 1/31/2013 E0163323-0012-01 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS OXYTOCIN 10 UNITS/ML VIAL 9/1/2010 99/99/9999 E0163323-0012-10 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS OXYTOCIN 10 UNITS/ML VIAL 9/1/2010 99/99/9999 E0163323-0012-30 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS OXYTOCIN 10 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100075-2451-01 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 M DDAVP 4 MCG/ML AMPUL 9/1/2010 99/99/9999 E0100075-2451-53 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 M DDAVP 4 MCG/ML VIAL 9/1/2010 99/99/9999 E0100409-2265-01 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 M DESMOPRESSIN AC 4 MCG/ML AMPUL 9/1/2010 99/99/9999 E0100703-5051-03 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 M DESMOPRESSIN AC 4 MCG/ML VIAL 9/1/2010 99/99/9999 E0100703-5054-01 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 M DESMOPRESSIN AC 4 MCG/ML VIAL 9/1/2010 99/99/9999 E0155566-5030-01 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 M DESMOPRESSIN AC 4 MCG/ML AMPUL 9/1/2010 99/99/9999 E0155566-5040-01 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 M DESMOPRESSIN AC 4 MCG/ML VIAL 9/1/2010 99/99/9999 E0100574-0430-00 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE PWD MICRONIZED 9/1/2010 7/31/2011 E0100574-0431-01 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0100591-3128-79 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE OIL 50 MG/ML VL 9/1/2010 99/99/9999 E0139822-6000-01 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE PWD MICRONIZED 9/1/2010 2/28/2013 E0139822-6000-03 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE PWD MICRONIZED 9/1/2010 2/28/2013 E0139822-6000-07 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE PWD MICRONIZED 9/1/2010 2/28/2013 E0139822-6100-01 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWD WETTABLE 9/1/2010 6/30/2013 E0139822-6100-03 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWD WETTABLE 9/1/2010 6/30/2013 E0139822-6100-05 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWD WETTABLE 9/1/2010 12/31/2010 E0139822-6100-07 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWD WETTABLE 9/1/2010 6/30/2013 E0151552-0005-01 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0005-03 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0005-04 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0005-05 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0005-07 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0006-01 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0006-03 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0006-04 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0006-05 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0006-07 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0151552-0643-07 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE POWDER 9/1/2010 3/31/2011 E0163323-0261-10 J2675 INJECTION, PROGESTERONE, PER 50 MG PROGESTERONE OIL 50 MG/ML VL 9/1/2010 99/99/9999 E0155390-0465-05 J2680 INJECTION, FLUPHENAZINE DECANOATE, UP TO FLUPHENAZINE DEC 25 MG/ML VL 9/1/2010 9/30/2011 E0160505-0664-02 J2680 INJECTION, FLUPHENAZINE DECANOATE, UP TO FLUPHENAZINE DEC 25 MG/ML VL 9/1/2010 99/99/9999 E0163323-0272-05 J2680 INJECTION, FLUPHENAZINE DECANOATE, UP TO FLUPHENAZINE DEC 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1902-01 J2690 INJECTION, PROCAINAMIDE HCL, UP TO 1 G PROCAINAMIDE 100 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1903-01 J2690 INJECTION, PROCAINAMIDE HCL, UP TO 1 G PROCAINAMIDE 500 MG/ML VIAL 9/1/2010 99/99/9999 E0100338-1013-41 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 1 GM/ 50 ML INJ 9/1/2010 99/99/9999 E0100338-1015-41 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 2 GM/ 50 ML INJ 9/1/2010 99/99/9999 E0100781-3099-95 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3101-95 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100781-3103-95 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9109-95 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 1 GM VIAL 9/1/2010 99/99/9999 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00781-9111-95 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100781-9113-95 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 M OXACILLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100517-0033-25 J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP NEOSTIGMINE 1:1,000 VIAL 9/1/2010 99/99/9999 E0100517-0034-25 J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP NEOSTIGMINE 1:2,000 VIAL 9/1/2010 99/99/9999 E0110019-0270-10 J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP NEOSTIGMINE 1:1,000 VIAL 9/1/2010 7/31/2013 E0110019-0271-10 J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP NEOSTIGMINE 1:2,000 VIAL 9/1/2010 7/31/2013 E0163323-0382-10 J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP NEOSTIGMINE 1:2,000 VIAL 9/1/2010 99/99/9999 E0163323-0383-10 J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP NEOSTIGMINE 1:1,000 VIAL 9/1/2010 99/99/9999 E0163323-0229-05 J2720 INJECTION, PROTAMINE SULFATE, UP TO 10 M PROTAMINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0229-30 J2720 INJECTION, PROTAMINE SULFATE, UP TO 10 M PROTAMINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100944-4175-05 J2724 INJECTION, PROTEIN C CONCENTRATE, INTRAV CEPROTIN 400-600 UNITS VIAL 9/1/2010 99/99/9999 E0100944-4175-10 J2724 INJECTION, PROTEIN C CONCENTRATE, INTRAV CEPROTIN 800-1,200 UNITS VIAL 9/1/2010 99/99/9999 E0160977-0141-01 J2730 INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 PROTOPAM CHLORIDE 1 GM VIAL 9/1/2010 99/99/9999 E0160977-0141-27 J2730 INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 PROTOPAM CHLORIDE 1 GM VIAL 9/1/2010 99/99/9999 E0138779-1502-09 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0151552-0496-01 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0151552-0496-02 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0151552-0496-04 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0151552-0496-05 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0151552-0496-09 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0155390-0113-01 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE 5 MG VIAL 9/1/2010 9/30/2015 E0138779-1502-03 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0138779-1502-00 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0138779-1502-06 J2760 INJECTION, PHENTOLAINE MESYLATE, UP TO 5 PHENTOLAMINE MESYLATE POWDER 9/1/2010 3/31/2011 E0100409-2173-32 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 METOCLOPRAMIDE 5 MG/ML SYR 9/1/2010 9/30/2011 E0100409-3413-01 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 METOCLOPRAMIDE 5 MG/ML AMPUL 9/1/2010 9/30/2011 E0100703-4502-04 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 METOCLOPRAMIDE 10 MG/2 ML VIAL 9/1/2010 99/99/9999 E0110019-0450-02 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 METOCLOPRAMIDE 5 MG/ML VIAL 9/1/2010 12/31/2011 E0151552-0180-03 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 METOCLOPRAMIDE HCL POWDER 9/1/2010 3/31/2011 E0151552-0180-05 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 METOCLOPRAMIDE HCL POWDER 9/1/2010 3/31/2011 E0160977-0451-01 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 REGLAN 5 MG/ML VIAL 9/1/2010 12/31/2011 E0160977-0451-02 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 REGLAN 5 MG/ML VIAL 9/1/2010 12/31/2011 E0160977-0451-03 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 REGLAN 5 MG/ML VIAL 9/1/2010 12/31/2011 E0100409-3414-01 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 METOCLOPRAMIDE 10 MG/2 ML VIAL 9/1/2010 99/99/9999 E0161570-0260-10 J2770 INJECTION, QUINUPRISTIN/DALFOPRISTIN, 50 SYNERCID 500 MG VIAL 9/1/2010 99/99/9999 E0100173-0362-38 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M ZANTAC 25 MG/ML VIAL 9/1/2010 8/31/2014 E0100173-0363-00 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M ZANTAC 25 MG/ML VIAL 9/1/2010 5/31/2014 E0100173-0363-01 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M ZANTAC 150 MG/6 ML VIAL 9/1/2010 6/20/2014 E0100173-0441-00 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M ZANTAC 50 MG/50 ML PLAST-BAG 9/1/2010 10/1/2013 E0151552-0620-02 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M RANITIDINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0620-04 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M RANITIDINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0620-05 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M RANITIDINE HCL POWDER 9/1/2010 3/31/2011 E0155390-0616-01 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M RANITIDINE HCL 25 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0616-10 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M RANITIDINE HCL 25 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0618-01 J2780 INJECTION, RANITIDINE HCL (ZANTAC), 25 M RANITIDINE 1,000 MG/40 ML VIAL 9/1/2010 3/31/2014 E0100024-5150-10 J2783 INJECTION, RASBURICASE, 0.5 MG ELITEK 1.5 MG VIAL 9/1/2010 99/99/9999 E0100024-5151-75 J2783 INJECTION, RASBURICASE, 0.5 MG ELITEK 7.5 MG VIAL 9/1/2010 99/99/9999 E0100469-6501-89 J2785 INJECTION, REGADENOSON, 0.1 MG LEXISCAN INJECTION 9/1/2010 99/99/9999 E0144206-0300-01 J2791 INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN RHOPHYLAC 300 MCG/2 ML SYR 9/1/2010 99/99/9999 E0144206-0300-10 J2791 INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN RHOPHYLAC 300 MCG/2 ML SYR 9/1/2010 99/99/9999 E0100944-2950-02 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 600 UNITS VIAL 9/1/2010 12/31/2010 E0100944-2950-04 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 1,500 UNITS VIAL 9/1/2010 12/31/2010 E0100944-2950-06 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 5,000 UNITS VIAL 9/1/2010 12/31/2010 E0100944-2967-01 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 600 UNITS VIAL 9/1/2010 12/31/2010 E0100944-2967-03 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 1,500 UNITS VIAL 9/1/2010 9/30/2012 E0100944-2967-05 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 5,000 UNITS VIAL 9/1/2010 9/30/2012 E0100944-2967-07 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 2,500 UNITS VIAL 9/1/2010 10/31/2012 E0100944-2967-09 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV WINRHO SDF 15,000 UNITS VIAL 9/1/2010 10/31/2012 E0113533-0631-02 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV HYPERRHO S-D SYRINGE 9/1/2010 99/99/9999 E0113533-0631-06 J2792 INJECTION, RHO D IMMUNE GLOBULIN, INTRAV HYPERRHO S-D 250 UNITS SYRINGE 9/1/2010 99/99/9999 E0150458-0306-11 J2794 RISPERIDONE, LONG ACTING, 0.5 MG RISPERDAL CONSTA 25 MG SYR 9/1/2010 99/99/9999 E0150458-0307-11 J2794 RISPERIDONE, LONG ACTING, 0.5 MG RISPERDAL CONSTA 37.5 MG SYR 9/1/2010 99/99/9999 E0150458-0308-11 J2794 RISPERIDONE, LONG ACTING, 0.5 MG RISPERDAL CONSTA 50 MG SYR 9/1/2010 99/99/9999 E0150458-0309-11 J2794 RISPERIDONE, LONG ACTING, 0.5 MG RISPERDAL CONSTA 12.5 MG SYR 9/1/2010 99/99/9999 E0100186-0859-44 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 2 MG/ML AMPULE 9/1/2010 6/30/2014 E0100186-0859-54 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 2 MG/ML AMPULE 9/1/2010 6/30/2014 E0100186-0859-81 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 2 MG/ML INFUSION BTL 9/1/2010 4/30/2013 E0100186-0859-91 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 2 MG/ML INFUSION BTL 9/1/2010 6/30/2013 E0100186-0863-54 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 5 MG/ML AMPULE 9/1/2010 6/30/2014 E0100186-0863-61 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 5 MG/ML VIAL 9/1/2010 4/30/2013 E0100186-0863-69 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 5 MG/ML VIAL 9/1/2010 3/31/2012 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00186-0867-54 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 7.5 MG/ML AMPULE 9/1/2010 6/30/2014 E0100186-0868-44 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 10 MG/ML AMPULE 9/1/2010 6/30/2014 E0100186-0868-54 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1M NAROPIN 10 MG/ML AMPULE 9/1/2010 6/30/2014 E0155513-0221-01 J2796 INJECTION, ROMIPLOSTIM, 10 MCG NPLATE 250 MCG VIAL 9/1/2010 99/99/9999 E0155513-0222-01 J2796 INJECTION, ROMIPLOSTIM, 10 MCG NPLATE 500 MCG VIAL 9/1/2010 99/99/9999 E0160977-0150-01 J2800 INJECTION, METHOCARBAMOL, UP TO 10 ML ROBAXIN 100 MG/ML VIAL 9/1/2010 4/30/2014 E0100264-9554-00 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 800 MG/1 L D5W 9/1/2010 12/31/2011 E0100264-9554-10 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 400 MG/500 ML D5W 9/1/2010 99/99/9999 E0100264-9558-10 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 800 MG/500 ML D5W 9/1/2010 9/30/2013 E0100338-0439-03 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 400 MG/500 ML D5W 9/1/2010 9/30/2010 E0100338-0441-03 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 800 MG/500 ML D5W 9/1/2010 12/31/2010 E0100409-7666-62 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 400 MG/250 ML D5W 9/1/2010 9/30/2011 E0100409-7668-23 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 200 MG/100 ML D5W 9/1/2010 9/30/2011 E0100409-7677-13 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 200 MG/50 ML D5W 9/1/2010 9/30/2011 E0100409-7705-62 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE 800 MG/250 ML D5W 9/1/2010 9/30/2011 E0151552-0487-05 J2810 INJECTION, THEOPHYLLINE, UP TO 40 MG THEOPHYLLINE ANHYDROUS PWD 9/1/2010 3/31/2011 E0150419-0002-33 J2820 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG LEUKINE 250 MCG VIAL 9/1/2010 7/31/2012 E0150419-0050-30 J2820 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG LEUKINE 500 MCG/ML VIAL 9/1/2010 3/31/2011 E0150419-0595-01 J2820 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG LEUKINE 500 MCG/ML VIAL 9/1/2010 12/31/2010 E0150419-0595-05 J2820 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG LEUKINE 500 MCG/ML VIAL 9/1/2010 12/31/2010 E0100591-0149-87 J2916 SODIUM FERRIC GLUCONATE COMPLEX IN SUCRO SOD FER GLUC CPLX 62.5 MG/5 ML 8/16/2012 99/99/9999 E0152544-0149-87 J2916 SODIUM FERRIC GLUCONATE COMPLEX IN SUCRO NULECIT 62.5 MG/5 ML VIAL 5/25/2011 99/99/9999 E0100024-2791-50 J2916 SODIUM FERRIC GLUCONATE COMPLEX IN SUCRO FERRLECIT 62.5 MG/5 ML AMPUL 9/1/2010 10/31/2014 E0100024-2792-10 J2916 SODIUM FERRIC GLUCONATE COMPLEX IN SUCRO FERRLECIT 62.5 MG/5 ML VIAL 7/1/2011 99/99/9999 E0152544-0922-26 J2916 SODIUM FERRIC GLUCONATE COMPLEX IN SUCRO FERRLECIT 62.5 MG/5 ML AMPUL 9/1/2010 10/31/2011 E0100009-0113-19 J2920 INJECTION, METHYLPREDNISOLONE SODIUM SUC SOLU-MEDROL 40 MG VIAL 9/1/2010 12/31/2011 E0100409-3217-05 J2920 INJECTION, METHYLPREDNISOLONE SODIUM SUC A-METHAPRED 40 MG VIAL 9/1/2010 3/31/2013 E0155390-0209-10 J2920 INJECTION, METHYLPREDNISOLONE SODIUM SUC METHYLPREDNISOLONE 40 MG VIAL 9/1/2010 9/30/2011 E0163323-0255-03 J2920 INJECTION, METHYLPREDNISOLONE SODIUM SUC METHYLPREDNISOLONE 40 MG VIAL 9/1/2010 99/99/9999 E0100009-0190-16 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC SOLU-MEDROL 125 MG VIAL 9/1/2010 12/1/2012 E0100009-0698-01 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC SOLU-MEDROL 1 GM VIAL 9/1/2010 99/99/9999 E0100009-0758-01 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC SOLU-MEDROL 500 MG VIAL 9/1/2010 99/99/9999 E0100009-0765-02 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC SOLU-MEDROL 500 MG VIAL 9/1/2010 9/1/2011 E0100009-0796-01 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC SOLU-MEDROL 2,000 MG VIAL 9/1/2010 99/99/9999 E0100009-3389-01 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC SOLU-MEDROL 1,000 MG VIAL 9/1/2010 11/1/2012 E0100409-3218-05 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC A-METHAPRED 125 MG VIAL 9/1/2010 3/31/2013 E0100409-5685-02 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC A-METHAPRED 125 MG VIAL 9/1/2010 9/30/2011 E0155390-0210-10 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC METHYLPREDNISOLONE 125 MG VIAL 9/1/2010 9/30/2011 E0163323-0258-03 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC METHYLPREDNISOLONE 125 MG VIAL 9/1/2010 99/99/9999 E0163323-0265-30 J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUC METHYLPREDNISOLONE SS 1 GM VL 9/1/2010 99/99/9999 E0100002-7335-01 J2941 INJECTION, SOMATROPIN, 1MG HUMATROPE 5 MG VIAL 9/1/2010 12/31/2011 E0100002-7335-11 J2941 INJECTION, SOMATROPIN, 1MG HUMATROPE 5 MG VIAL 9/1/2010 99/99/9999 E0100002-7335-16 J2941 INJECTION, SOMATROPIN, 1MG HUMATROPE 5 MG VIAL 9/1/2010 3/31/2013 E0100002-8147-01 J2941 INJECTION, SOMATROPIN, 1MG HUMATROPE 6 MG CARTRIDGE 9/1/2010 99/99/9999 E0100002-8148-01 J2941 INJECTION, SOMATROPIN, 1MG HUMATROPE 12 MG CARTRIDGE 9/1/2010 99/99/9999 E0100002-8149-01 J2941 INJECTION, SOMATROPIN, 1MG HUMATROPE 24 MG CARTRIDGE 9/1/2010 99/99/9999 E0100013-2626-81 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN 5 MG CARTRIDGE 9/1/2010 99/99/9999 E0100013-2646-81 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN 12 MG CARTRIDGE 9/1/2010 99/99/9999 E0100013-2649-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 0.2 MG 9/1/2010 99/99/9999 E0100013-2650-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 0.4 MG 9/1/2010 99/99/9999 E0100013-2651-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 0.6 MG 9/1/2010 99/99/9999 E0100013-2652-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 0.8 MG 9/1/2010 99/99/9999 E0100013-2653-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 1 MG 9/1/2010 99/99/9999 E0100013-2654-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 1.2 MG 9/1/2010 99/99/9999 E0100013-2655-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 1.4 MG 9/1/2010 99/99/9999 E0100013-2656-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 1.6 MG 9/1/2010 99/99/9999 E0100013-2657-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 1.8 MG 9/1/2010 99/99/9999 E0100013-2658-02 J2941 INJECTION, SOMATROPIN, 1MG GENOTROPIN MINIQUICK 2 MG 9/1/2010 99/99/9999 E0100169-7704-11 J2941 INJECTION, SOMATROPIN, 1MG NORDITROPIN NORDIFLEX 5 MG/1.5 9/1/2010 6/30/2012 E0100169-7705-11 J2941 INJECTION, SOMATROPIN, 1MG NORDITROPIN NORDIFLX 10 MG/1.5 9/1/2010 9/30/2012 E0100169-7708-11 J2941 INJECTION, SOMATROPIN, 1MG NORDITROPIN NORDIFLX 15 MG/1.5 9/1/2010 9/30/2012 E0100169-7768-11 J2941 INJECTION, SOMATROPIN, 1MG NORDITROPIN 5 MG/1.5 ML CRTG 9/1/2010 3/31/2012 E0100169-7770-11 J2941 INJECTION, SOMATROPIN, 1MG NORDITROPIN 15 MG/1.5 ML CRTG 9/1/2010 11/30/2011 E0100781-4004-36 J2941 INJECTION, SOMATROPIN, 1MG OMNITROPE 5.8 MG VIAL 9/1/2010 99/99/9999 E0144087-0004-07 J2941 INJECTION, SOMATROPIN, 1MG SEROSTIM 4 MG VIAL 9/1/2010 99/99/9999 E0144087-0005-07 J2941 INJECTION, SOMATROPIN, 1MG SEROSTIM 5 MG VIAL 9/1/2010 99/99/9999 E0144087-0006-07 J2941 INJECTION, SOMATROPIN, 1MG SEROSTIM 6 MG VIAL 9/1/2010 99/99/9999 E0144087-1005-02 J2941 INJECTION, SOMATROPIN, 1MG SAIZEN 5 MG VIAL 9/1/2010 99/99/9999 E0144087-1080-01 J2941 INJECTION, SOMATROPIN, 1MG SAIZEN 8.8 MG CLICK.EASY CARTG 9/1/2010 99/99/9999 E0144087-1088-01 J2941 INJECTION, SOMATROPIN, 1MG SAIZEN 8.8 MG VIAL 9/1/2010 99/99/9999 E0144087-3388-07 J2941 INJECTION, SOMATROPIN, 1MG ZORBTIVE 8.8 MG VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

50242-0018-21 J2941 INJECTION, SOMATROPIN, 1MG NUTROPIN 10 MG VIAL 9/1/2010 11/30/2013 E0150242-0019-02 J2941 INJECTION, SOMATROPIN, 1MG NUTROPIN 5 MG VIAL 9/1/2010 5/31/2012 E0150242-0020-20 J2941 INJECTION, SOMATROPIN, 1MG NUTROPIN 10 MG VIAL 9/1/2010 11/30/2013 E0150242-0022-20 J2941 INJECTION, SOMATROPIN, 1MG NUTROPIN AQ 5 MG/ML VIAL 9/1/2010 3/31/2013 E0150242-0043-14 J2941 INJECTION, SOMATROPIN, 1MG NUTROPIN AQ PEN CARTRIDGE 9/1/2010 99/99/9999 E0150242-0072-03 J2941 INJECTION, SOMATROPIN, 1MG NUTROPIN 5 MG VIAL 9/1/2010 5/31/2012 E0157844-0713-19 J2941 INJECTION, SOMATROPIN, 1MG TEV-TROPIN 5 MG VIAL 9/1/2010 99/99/9999 E0150242-0041-63 J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG CATHFLO ACTIVASE 2 MG VIAL 9/1/2010 99/99/9999 E0150242-0041-64 J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG CATHFLO ACTIVASE 2 MG VIAL 9/1/2010 99/99/9999 E0150242-0044-13 J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG ACTIVASE 50 MG VIAL 9/1/2010 99/99/9999 E0150242-0085-27 J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG ACTIVASE 100 MG VIAL 9/1/2010 99/99/9999 E0139822-0706-01 J3000 INJECTION, STREPTOMYCIN, UP TO 1 G STREPTOMYCIN SULF 1 GM VIAL 9/1/2010 99/99/9999 E0151552-0978-05 J3000 INJECTION, STREPTOMYCIN, UP TO 1 G STREPTOMYCIN SULFATE POWDER 9/1/2010 3/31/2011 E0139822-0706-02 J3000 INJECTION, STREPTOMYCIN, UP TO 1 G STREPTOMYCIN SULF 1 GM VIAL 9/1/2010 99/99/9999 E0100406-1130-52 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL CITRATE POWDER 9/1/2010 3/31/2011 E0100409-1276-32 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-9093-35 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-9093-36 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 9/1/2011 E0100409-9093-38 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-9094-22 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-9094-25 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-9094-28 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-9094-31 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-9094-61 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0033-72 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 5/31/2015 E0110019-0035-74 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 99/99/9999 E0110019-0037-83 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML VIAL 9/1/2010 5/31/2014 E0110019-0038-67 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 4/30/2015 E0111098-0030-02 J3010 INJECTION, FENTANYL CITRATE, 0.1MG SUBLIMAZE 0.05 MG/ML AMPUL 9/1/2010 12/31/2011 E0111098-0030-05 J3010 INJECTION, FENTANYL CITRATE, 0.1MG SUBLIMAZE 0.05 MG/ML AMPUL 9/1/2010 7/31/2011 E0111098-0030-20 J3010 INJECTION, FENTANYL CITRATE, 0.1MG SUBLIMAZE 0.05 MG/ML AMPUL 9/1/2010 9/30/2011 E0151552-0687-01 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL CITRATE POWDER 9/1/2010 3/31/2011 E0151552-0687-09 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL CITRATE POWDER 9/1/2010 3/31/2011 E0100409-9093-32 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 99/99/9999 E0138779-1756-03 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL CITRATE POWDER 9/1/2010 3/31/2011 E0138779-1756-04 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL CITRATE POWDER 9/1/2010 12/31/2012 E0110019-0038-39 J3010 INJECTION, FENTANYL CITRATE, 0.1MG FENTANYL 0.05 MG/ML AMPUL 9/1/2010 4/30/2015 E0100173-0449-02 J3030 INJECTION, SUMATRIPTAN SUCCINATE, 6 MG, IMITREX 6 MG/0.5 ML VIAL 9/1/2010 99/99/9999 E0100173-0739-00 J3030 INJECTION, SUMATRIPTAN SUCCINATE, 6 MG, IMITREX 4 MG/0.5 ML PEN INJECT 9/1/2010 99/99/9999 E0100173-0739-02 J3030 INJECTION, SUMATRIPTAN SUCCINATE, 6 MG, IMITREX 4 MG/0.5 ML CARTRIDGES 9/1/2010 99/99/9999 E0100409-1920-10 J3070 INJECTION, PENTAZOCINE HCL, 30 MG TALWIN 30 MG/ML VIAL 9/1/2010 3/1/2012 E0100409-1941-01 J3070 INJECTION, PENTAZOCINE HCL, 30 MG TALWIN 30 MG/ML AMPUL 9/1/2010 99/99/9999 E0100703-1271-04 J3105 INJECTION, TERBUTALINE SULFATE, UP TO 1 TERBUTALINE SULF 1 MG/ML VIAL 9/1/2010 12/31/2011 E0155390-0101-10 J3105 INJECTION, TERBUTALINE SULFATE, UP TO 1 TERBUTALINE SULF 1 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0193-10 J3105 INJECTION, TERBUTALINE SULFATE, UP TO 1 TERBUTALINE SULF 1 MG/ML VIAL 9/1/2010 6/30/2012 E0163323-0665-01 J3105 INJECTION, TERBUTALINE SULFATE, UP TO 1 TERBUTALINE SULF 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100574-0821-05 J3130 INJECTION, TESTOSTERONE ENANTHATE, UP TO TESTOSTERONE ENAN 200 MG/ML 9/1/2010 9/30/2011 E0100591-3221-26 J3130 INJECTION, TESTOSTERONE ENANTHATE, UP TO TESTOSTERONE ENAN 200 MG/ML 9/1/2010 99/99/9999 E0154396-0328-40 J3130 INJECTION, TESTOSTERONE ENANTHATE, UP TO DELATESTRYL 200 MG/ML VIAL 9/1/2010 12/31/2010 E0100574-0460-05 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0100574-0460-25 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0029-01 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0029-02 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0029-04 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0029-05 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0029-07 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0564-04 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0564-05 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0151552-0564-07 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP T TESTOSTERONE POWDER 9/1/2010 3/31/2011 E0100574-0461-05 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0100574-0461-25 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0030-01 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0030-02 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0030-04 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0030-05 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0030-08 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0030-09 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP T TESTOSTERONE PROPIONATE POWDER 9/1/2010 3/31/2011 E0100641-1397-35 J3230 INJECTION, CHLORPROMAZINE HCL, UP TO 50 CHLORPROMAZINE 25 MG/ML AMP 9/1/2010 99/99/9999 E0100641-1398-35 J3230 INJECTION, CHLORPROMAZINE HCL, UP TO 50 CHLORPROMAZINE 25 MG/ML AMP 9/1/2010 99/99/9999 E0151552-0139-04 J3230 INJECTION, CHLORPROMAZINE HCL, UP TO 50 CHLORPROMAZINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0139-05 J3230 INJECTION, CHLORPROMAZINE HCL, UP TO 50 CHLORPROMAZINE HCL POWDER 9/1/2010 3/31/2011 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

58468-1849-04 J3240 INJECTION, THYROTROPIN ALPHA, 0.9 MG, PR THYROGEN 1.1 MG VIAL 9/1/2010 99/99/9999 E0100008-4990-02 J3243 INJECTION, TIGECYCLINE, 1 MG TYGACIL 50 MG VIAL 9/1/2010 99/99/9999 E0100409-1952-32 J3250 INJECTION, TRIMETHOBENZAMIDE HCL, UP TO TRIMETHOBENZAMIDE 100 MG/ML 9/1/2010 7/1/2011 E0161570-0541-20 J3250 INJECTION, TRIMETHOBENZAMIDE HCL, UP TO TIGAN 100 MG/ML VIAL 9/1/2010 9/30/2010 E0161570-0543-25 J3250 INJECTION, TRIMETHOBENZAMIDE HCL, UP TO TIGAN 100 MG/ML VIAL 9/1/2010 9/30/2010 E0100409-3255-03 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-3469-13 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 60 MG/50 ML NS 9/1/2010 9/30/2011 E0100409-3470-23 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 80 MG/100 ML NS 9/1/2010 99/99/9999 E0100409-3577-01 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-3578-01 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 80 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-3590-02 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-9402-04 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-9416-01 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 40 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0305-02 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 10 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0306-02 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 40 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0307-51 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 TOBRAMYCIN 40 MG/ML VIAL 9/1/2010 99/99/9999 E0166302-0101-01 J3285 INJECTION, TREPROSTINIL, 1 MG REMODULIN 1 MG/ML VIAL 9/1/2010 99/99/9999 E0166302-0102-01 J3285 INJECTION, TREPROSTINIL, 1 MG REMODULIN 2.5 MG/ML VIAL 9/1/2010 99/99/9999 E0166302-0105-01 J3285 INJECTION, TREPROSTINIL, 1 MG REMODULIN 5 MG/ML VIAL 9/1/2010 99/99/9999 E0166302-0110-01 J3285 INJECTION, TREPROSTINIL, 1 MG REMODULIN 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100065-0543-01 J3300 INJECTION, TRIAMCINOLONE ACETONIDE, PRES TRIESENCE 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100003-0293-05 J3300 INJECTION, TRIAMCINOLONE ACETONIDE, PRES KENALOG-40 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100003-0494-20 J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT KENALOG-10 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100003-0293-05 J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT KENALOG-40 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100003-0293-20 J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT KENALOG-40 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100003-0293-28 J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT KENALOG-40 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100781-3085-71 J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT ARISTOSPAN 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100781-3085-75 J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT ARISTOSPAN 20 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0278-01 J3302 INJECTION, TRIAMCINOLONE DIACETATE, PER TRIAMCINOLONE DIACETATE POWDER 9/1/2010 3/31/2011 E0151552-0278-02 J3302 INJECTION, TRIAMCINOLONE DIACETATE, PER TRIAMCINOLONE DIACETATE POWDER 9/1/2010 3/31/2011 E0151552-0278-03 J3302 INJECTION, TRIAMCINOLONE DIACETATE, PER TRIAMCINOLONE DIACETATE POWDER 9/1/2010 3/31/2011 E0100781-3084-75 J3303 INJECTION, TRIAMCINOLONE HEXACETONIDE, P ARISTOSPAN 5 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0057-04 J3350 INJECTION, UREA, UP TO 40 GM UREA BEADS 9/1/2010 3/31/2011 E0155566-8505-02 J3355 INJECTION, UROFOLLITROPIN BRAVELLE 75 UNIT VIAL 9/1/2010 99/99/9999 E0155566-8505-06 J3355 INJECTION, UROFOLLITROPIN BRAVELLE 75 UNIT VIAL 9/1/2010 99/99/9999 E0100409-1273-32 J3360 INJECTION, DIAZEPAM, UP TO 5 MG DIAZEPAM 5 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-3213-02 J3360 INJECTION, DIAZEPAM, UP TO 5 MG DIAZEPAM 5 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-3213-12 J3360 INJECTION, DIAZEPAM, UP TO 5 MG DIAZEPAM 5 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-1025-02 J3360 INJECTION, DIAZEPAM, UP TO 5 MG DIAZEPAM POWDER 9/1/2010 3/31/2011 E0151552-1025-04 J3360 INJECTION, DIAZEPAM, UP TO 5 MG DIAZEPAM POWDER 9/1/2010 3/31/2011 E0151552-1025-05 J3360 INJECTION, DIAZEPAM, UP TO 5 MG DIAZEPAM POWDER 9/1/2010 3/31/2011 E0124430-1003-01 J3364 INJECTION, UROKINASE, 5000 IU VIAL KINLYTIC 250,000 UNITS VIAL 9/1/2010 12/31/2010 E0124430-1003-01 J3365 INJECTION, IV, UROKINASE, 250,000 I.U. V KINLYTIC 250,000 UNITS VIAL 9/1/2010 12/31/2010 E0124430-1001-01 J3365 INJECTION, IV, UROKINASE, 250,000 I.U. V ABBOKINASE 250,000 UNITS VIAL 9/1/2010 12/31/2010 E0100338-3551-48 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN-D5W 500 MG/100 ML 9/1/2010 99/99/9999 E0100338-3552-48 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 1G/200 ML BAG 9/1/2010 99/99/9999 E0100409-4332-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 9/1/2010 99/99/9999 E0100409-4332-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 9/1/2010 99/99/9999 E0100409-6509-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 9/1/2010 99/99/9999 E0100409-6509-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 9/1/2010 99/99/9999 E0100409-6533-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 9/1/2010 99/99/9999 E0100409-6533-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 9/1/2010 99/99/9999 E0100409-6533-61 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 9/1/2010 9/30/2011 E0100409-6534-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG A-V VIAL 9/1/2010 99/99/9999 E0100409-6534-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG A-V VIAL 9/1/2010 99/99/9999 E0100409-6535-01 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM ADD-VAN VIAL 9/1/2010 99/99/9999 E0100409-6535-49 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM ADD-VAN VIAL 9/1/2010 99/99/9999 E0163323-0221-10 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0284-20 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0295-61 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 5 GM VIAL 9/1/2010 99/99/9999 E0163323-0314-61 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG VANCOMYCIN HCL 10 GM VIAL 9/1/2010 99/99/9999 E0100078-0437-61 J3396 VERTEPORFIN VISUDYNE 15 MG VIAL 9/1/2010 11/30/2011 E0100517-4201-25 J3410 INJECTION, HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-5601-25 J3410 INJECTION, HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-5602-25 J3410 INJECTION, HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-5610-25 J3410 INJECTION, HYDROXYZINE HCL, UP TO 25 MG HYDROXYZINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0013-02 J3411 THIAMINE HCI, INJECTION THIAMINE 200 MG/2 ML VIAL 9/1/2010 99/99/9999 E0151552-0149-04 J3415 INJECTION PYRIDOXINE PYRIDOXINE HCL CRYSTALS 9/1/2010 3/31/2011 E0163323-0180-01 J3415 INJECTION PYRIDOXINE PYRIDOXINE 100 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-0031-25 J3420 INJECTION, VITAMIN B- 12 CYANOCOBALAMIN, CYANOCOBALAMIN 1,000 MCG/ML 9/1/2010 99/99/9999 E0100517-0032-25 J3420 INJECTION, VITAMIN B- 12 CYANOCOBALAMIN, CYANOCOBALAMIN 1,000 MCG/ML 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00517-0130-05 J3420 INJECTION, VITAMIN B- 12 CYANOCOBALAMIN, CYANOCOBALAMIN 1,000 MCG/ML 9/1/2010 99/99/9999 E0163323-0044-01 J3420 INJECTION, VITAMIN B- 12 CYANOCOBALAMIN, CYANOCOBALAMIN 1,000 MCG/ML 9/1/2010 99/99/9999 E0151552-1063-02 J3430 INJECTION, VITAMIN K, PHYTONADIONE, VITAMIN K1 LIQUID 9/1/2010 3/31/2011 E0100049-3190-28 J3465 VORICONAZOLE, INJECTION VFEND IV 200 MG VIAL 9/1/2010 99/99/9999 E0100548-9090-00 J3470 INJECTION, HYALURONIDASE, UP TO 150 UNIT AMPHADASE 150 UNITS/ML VIAL 9/1/2010 99/99/9999 E0100548-9090-10 J3470 INJECTION, HYALURONIDASE, UP TO 150 UNIT AMPHADASE 150 UNITS/ML VIAL 9/1/2010 99/99/9999 E0160977-0319-03 J3470 INJECTION, HYALURONIDASE, UP TO 150 UNIT HYLENEX 150 UNITS/ML VIAL 9/1/2010 7/30/2011 E0167425-0002-10 J3470 INJECTION, HYALURONIDASE, UP TO 150 UNIT VITRASE 200 UNITS/ML VIAL 9/1/2010 99/99/9999 E0160977-0319-03 J3473 INJ, HYALURONIDASE, RECOMBINANT, 1 USP HYLENEX 150 UNITS/ML VIAL 9/1/2010 7/30/2011 E0100409-1754-10 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% SYRINGE 9/1/2010 99/99/9999 E0100409-2168-02 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0100409-2168-03 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 9/30/2011 E0100409-6727-23 J3475 MAGNESIUM SULFATE MAGNESIUM-D5W 1 GM/100 ML SOLN 9/1/2010 99/99/9999 E0100409-6729-03 J3475 MAGNESIUM SULFATE MAGNESIUM SULF 4% IV SOLN 9/1/2010 99/99/9999 E0100409-6729-09 J3475 MAGNESIUM SULFATE MAGNESIUM SULF 4% IV SOLN 9/1/2010 99/99/9999 E0100409-6729-23 J3475 MAGNESIUM SULFATE MAGNESIUM SULF 4% IV SOLN 9/1/2010 99/99/9999 E0100409-6729-24 J3475 MAGNESIUM SULFATE MAGNESIUM SULF 4% IV SOLN 9/1/2010 99/99/9999 E0100409-6730-13 J3475 MAGNESIUM SULFATE MAGNESIUM SULF 8% IV SOLN 9/1/2010 99/99/9999 E0100517-2602-25 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0100517-2610-25 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0100517-2650-25 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0124385-0807-01 J3475 MAGNESIUM SULFATE EPSOM SALT GRANULES 9/1/2010 99/99/9999 E0124385-0807-04 J3475 MAGNESIUM SULFATE EPSOM SALT GRANULES 9/1/2010 99/99/9999 E0149348-0018-63 J3475 MAGNESIUM SULFATE SM EPSOM SALT GRANULES 9/1/2010 99/99/9999 E0149348-0018-75 J3475 MAGNESIUM SULFATE SM EPSOM SALT GRANULES 9/1/2010 99/99/9999 E0151552-0376-04 J3475 MAGNESIUM SULFATE EPSOM SALT CRYSTALS 9/1/2010 3/31/2011 E0163323-0064-02 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0163323-0064-10 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0163323-0064-20 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0163323-0064-50 J3475 MAGNESIUM SULFATE MAGNESIUM SULFATE 50% VIAL 9/1/2010 99/99/9999 E0100264-1940-10 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 9/30/2011 E0100264-1940-20 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100264-7865-00 J3480 POTASSIUM CHLORIDE KCL 20 MEQ-NS 1,000 ML IV SOLN 9/1/2010 99/99/9999 E0100338-0318-02 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML IV SOL 9/1/2010 3/31/2011 E0100338-0691-04 J3480 POTASSIUM CHLORIDE KCL 20 MEQ-NS 1,000 ML IV SOLN 9/1/2010 99/99/9999 E0100338-0695-04 J3480 POTASSIUM CHLORIDE KCL 40 MEQ-NS 1,000 ML IV SOLN 9/1/2010 99/99/9999 E0100338-0703-41 J3480 POTASSIUM CHLORIDE POTASSIUM CL 20 MEQ/50 ML SOL 9/1/2010 99/99/9999 E0100338-0703-48 J3480 POTASSIUM CHLORIDE POTASSIUM CL 40 MEQ/100 ML SOL 9/1/2010 99/99/9999 E0100338-0704-34 J3480 POTASSIUM CHLORIDE POTASSIUM CL 20 MEQ-0.45% NACL 9/1/2010 99/99/9999 E0100338-0705-41 J3480 POTASSIUM CHLORIDE POTASSIUM CL 10 MEQ/50 ML SOL 9/1/2010 99/99/9999 E0100338-0705-48 J3480 POTASSIUM CHLORIDE POTASSIUM CL 20 MEQ/100 ML SOL 9/1/2010 99/99/9999 E0100338-0709-48 J3480 POTASSIUM CHLORIDE POTASSIUM CL 10 MEQ/100 ML SOL 9/1/2010 99/99/9999 E0100409-1513-02 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML IV SOL 9/1/2010 99/99/9999 E0100409-6635-01 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100409-6636-01 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100409-6651-06 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100409-6653-05 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100409-7074-26 J3480 POTASSIUM CHLORIDE POTASSIUM CL 10 MEQ/100 ML SOL 9/1/2010 99/99/9999 E0100409-7075-14 J3480 POTASSIUM CHLORIDE POTASSIUM CL 10 MEQ/50 ML SOL 9/1/2010 99/99/9999 E0100409-7075-26 J3480 POTASSIUM CHLORIDE POTASSIUM CL 20 MEQ/100 ML SOL 9/1/2010 99/99/9999 E0100409-7076-26 J3480 POTASSIUM CHLORIDE POTASSIUM CL 30 MEQ/100 ML SOL 9/1/2010 9/30/2011 E0100409-7077-14 J3480 POTASSIUM CHLORIDE POTASSIUM CL 20 MEQ/50 ML SOL 9/1/2010 99/99/9999 E0100409-7077-26 J3480 POTASSIUM CHLORIDE POTASSIUM CL 40 MEQ/100 ML SOL 9/1/2010 99/99/9999 E0100409-7115-09 J3480 POTASSIUM CHLORIDE KCL 20 MEQ-NS 1,000 ML IV SOLN 9/1/2010 99/99/9999 E0100409-7116-09 J3480 POTASSIUM CHLORIDE KCL 40 MEQ-NS 1,000 ML IV SOLN 9/1/2010 99/99/9999 E0163323-0965-05 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0163323-0965-10 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0163323-0965-15 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0163323-0965-20 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0163323-0967-30 J3480 POTASSIUM CHLORIDE POTASSIUM CL 2 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100173-0107-93 J3485 INJECTION, ZIDOVUDINE RETROVIR IV INFUSION VIAL 9/1/2010 5/31/2013 E0100049-3920-83 J3486 ZIPRASIDONE MESYLATE, INJECTION GEODON 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100078-0387-25 J3487 INJECTION, ZOLEDRONIC ACID ZOMETA 4 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100078-0435-61 J3488 RECLAST INJECTION RECLAST 5 MG/100 ML SOLUTION 9/1/2010 99/99/9999 E0151927-1000-00 J3490 UNCLASSIFIED DRUGS MORPHINE SULFATE POWDER 8/1/2014 99/99/9999 E0100009-0436-01 J3490 UNCLASSIFIED DRUGS R-GENE 10 VIAL 11/1/2013 99/99/9999 E0149452-2870-01 J3490 UNCLASSIFIED DRUGS ETHYL CHLORIDE SPRAY 11/1/2013 99/99/9999 E0150242-0087-01 J3490 UNCLASSIFIED DRUGS KADCYLA 160 MG VIAL 4/1/2013 12/31/2013 E0150242-0088-01 J3490 UNCLASSIFIED DRUGS KADCYLA 100 MG VIAL 4/1/2013 12/31/2013 E0150419-0422-01 J3490 UNCLASSIFIED DRUGS SKYLA SYSTEM 1/14/2013 12/31/2013 E0100023-3348-07 J3490 UNCLASSIFIED DRUGS OZURDEX 0.7 MG IMPLANT 9/1/2010 1/31/2013 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00065-0543-01 J3490 UNCLASSIFIED DRUGS TRIESENCE 40 MG/ML VIAL 9/1/2010 1/31/2013 E0163323-0270-25 J3490 UNCLASSIFIED DRUGS PROPOFOL 10 MG/ML VIAL 8/30/2011 12/27/2013 E0100409-1559-30 J3490 UNCLASSIFIED DRUGS MARCAINE 0.25% VIAL 9/1/2010 99/99/9999 E0150242-0145-01 J3590 UNCLASSIFIED BIOLOGICS PERJETA 420 MG/14 ML VIAL 8/29/2012 12/31/2013 E0163833-0825-02 J3590 UNCLASSIFIED BIOLOGICS BERINERT 500 UNIT KIT 9/1/2010 1/31/2013 E0100264-4000-55 J7030 INFUSION, NORMAL SALINE SOLUTION , 1000 SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 6/30/2015 E0100264-7800-00 J7030 INFUSION, NORMAL SALINE SOLUTION , 1000 SALINE 0.9% SOLN-EXCEL CONT 9/1/2010 99/99/9999 E0100338-0049-04 J7030 INFUSION, NORMAL SALINE SOLUTION , 1000 SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 99/99/9999 E0100409-7983-09 J7030 INFUSION, NORMAL SALINE SOLUTION , 1000 SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 99/99/9999 E0100409-7983-48 J7030 INFUSION, NORMAL SALINE SOLUTION , 1000 SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 12/1/2013 E0100264-4001-55 J7040 INFUSION, NORMAL SALINE SOLUTION, STERIL SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 9/30/2015 E0100264-7800-10 J7040 INFUSION, NORMAL SALINE SOLUTION, STERIL SALINE 0.9% SOLN-EXCEL CONT 9/1/2010 99/99/9999 E0100338-0044-03 J7040 INFUSION, NORMAL SALINE SOLUTION, STERIL SODIUM CHLORIDE 0.9% SOLN 9/1/2010 3/31/2011 E0100338-0049-03 J7040 INFUSION, NORMAL SALINE SOLUTION, STERIL SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 99/99/9999 E0100409-7983-03 J7040 INFUSION, NORMAL SALINE SOLUTION, STERIL SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 99/99/9999 E0100409-7983-30 J7040 INFUSION, NORMAL SALINE SOLUTION, STERIL SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 10/1/2013 E0100409-7983-55 J7040 INFUSION, NORMAL SALINE SOLUTION, STERIL SODIUM CHLORIDE 0.9% SOLUTION 9/1/2010 99/99/9999 E0100264-7610-00 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7610-10 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7610-20 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 7/31/2014 E0100338-0089-02 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-NS IV SOLUTION 9/1/2010 12/31/2010 E0100338-0089-03 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0089-04 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 99/99/9999 E0100409-7941-02 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 9/30/2011 E0100409-7941-03 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 99/99/9999 E0100409-7941-09 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN DEXTROSE 5%-0.9% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-6304-02 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100264-1800-32 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100264-4002-55 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 11/30/2013 E0100264-7800-20 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SALINE 0.9% SOLN-EXCEL CONT 9/1/2009 99/99/9999 E0100338-0044-02 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLN 9/1/2009 10/31/2009 E0100338-0049-01 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100338-0049-02 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100338-0049-18 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100338-0049-38 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100338-0049-41 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100338-0049-48 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100338-0553-18 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLN. 9/1/2009 99/99/9999 E0100409-1583-01 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 9/30/2011 E0100409-1583-02 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 9/30/2011 E0100409-1584-11 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 12/1/2011 E0100409-7101-02 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLN 9/1/2009 99/99/9999 E0100409-7101-67 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLN 9/1/2009 99/99/9999 E0100409-7983-02 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100409-7983-53 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100409-7983-61 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100409-7984-23 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100409-7984-37 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0163323-0186-00 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% VIAL 9/1/2009 99/99/9999 E0100409-1966-07 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C BACTERIOSTATIC SALINE VIAL 9/1/2009 99/99/9999 E0100409-7983-25 J7050 INFUSION, NORMAL SALINE SOLUTION , 250 C SODIUM CHLORIDE 0.9% SOLUTION 9/1/2009 99/99/9999 E0100264-1101-55 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 12/31/2014 E0100264-1102-55 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 12/31/2013 E0100264-1510-31 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-1510-32 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-1510-36 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-7510-00 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-7510-10 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-7510-20 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0016-02 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 9/30/2011 E0100338-0016-03 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 9/30/2011 E0100338-0017-01 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-02 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-03 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-04 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-10 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-11 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-18 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-31 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-38 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0017-41 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00338-0017-48 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0551-11 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100338-0551-18 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-1522-01 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 12/1/2011 E0100409-1522-02 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 12/31/2013 E0100409-1522-03 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 12/31/2013 E0100409-1523-01 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 9/30/2011 E0100409-1523-11 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 12/1/2011 E0100409-7100-02 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7100-66 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7100-67 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7922-02 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7922-03 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7922-09 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7922-30 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 5/1/2013 E0100409-7922-48 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 11/1/2013 E0100409-7922-53 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7922-55 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7922-61 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7923-13 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7923-20 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7923-23 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7923-36 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7923-37 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) DEXTROSE 5%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7418-03 J7100 INFUSION, DEXTRAN 40, 500 ML LMD 10% WITH 5% DEXT SOLN 9/1/2010 99/99/9999 E0100409-7419-03 J7100 INFUSION, DEXTRAN 40, 500 ML LMD 10% WITH 0.9% SOD CHL SOLN 9/1/2010 99/99/9999 E0100264-7750-00 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100264-7750-10 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100264-7750-20 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100264-7751-00 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC DEXTROSE 5%-LR IV SOLUTION 9/1/2010 99/99/9999 E0100264-7751-10 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC DEXTROSE 5%-LR IV SOLUTION 9/1/2010 99/99/9999 E0100338-0117-02 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100338-0117-03 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100338-0117-04 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100338-0125-03 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC DEXTROSE 5%-LR IV SOLUTION 9/1/2010 99/99/9999 E0100338-0125-04 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC DEXTROSE 5%-LR IV SOLUTION 9/1/2010 99/99/9999 E0100338-0811-04 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC KCL 20 MEQ IN D5W-LACT RINGER 9/1/2010 99/99/9999 E0100338-0815-04 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC KCL 40 MEQ IN D5W-LACT RINGER 9/1/2010 10/31/2010 E0100409-7111-09 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC KCL 20 MEQ IN D5W-LACT RINGER 9/1/2010 99/99/9999 E0100409-7113-09 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC KCL 40 MEQ IN D5W-LACT RINGER 9/1/2010 9/30/2011 E0100409-7929-03 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC DEXTROSE 5%-LR IV SOLUTION 9/1/2010 99/99/9999 E0100409-7929-09 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC DEXTROSE 5%-LR IV SOLUTION 9/1/2010 99/99/9999 E0100409-7953-02 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100409-7953-03 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100409-7953-09 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 99/99/9999 E0100409-7953-30 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 6/30/2014 E0100409-7953-48 J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC LACTATED RINGERS INJECTION 9/1/2010 11/1/2013 E0100053-7615-05 J7187 HUMATE-P, INJ HUMATE-P 600 UNIT VWF:RCO 9/1/2010 9/12/2011 E0100053-7615-10 J7187 HUMATE-P, INJ HUMATE-P 1,200 UNIT VWF:RCO 9/1/2010 11/17/2011 E0100053-7615-20 J7187 HUMATE-P, INJ HUMATE-P 2,400 UNIT VWF:RCO 9/1/2010 3/10/2012 E0100169-7060-01 J7189 FACTOR VIIA NOVOSEVEN 1,200 MCG VIAL 9/1/2010 3/31/2011 E0100169-7061-01 J7189 FACTOR VIIA NOVOSEVEN 2,400 MCG VIAL 9/1/2010 3/31/2011 E0100169-7062-01 J7189 FACTOR VIIA NOVOSEVEN 4,800 MCG VIAL 9/1/2010 2/28/2011 E0100053-7656-04 J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 1,000 UNITS KIT 9/1/2010 11/5/2012 E0100053-7656-05 J7190 FACTOR VIII, HUMAN, PER IU MONOCLATE-P 1,500 UNITS KIT 9/1/2010 10/28/2012 E0100944-1301-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 220-400 UNITS VIAL 9/1/2010 12/31/2010 E0100944-1302-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 401-800 UNITS VIAL 9/1/2010 12/31/2010 E0100944-1303-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 801-1,700 UNITS VIAL 9/1/2010 12/31/2010 E0100944-1304-10 J7190 FACTOR VIII, HUMAN, PER IU MONARC-M 1,701-2,000 UNITS VL 9/1/2010 12/31/2010 E0100944-2935-01 J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 220-400 UNITS VIAL 9/1/2010 12/31/2010 E0100944-2935-03 J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 801-1,700 UNITS VIAL 9/1/2010 12/31/2010 E0100944-2935-04 J7190 FACTOR VIII, HUMAN, PER IU HEMOFIL M 1,701-2,000 UNITS VL 9/1/2010 10/8/2010 E0100026-0372-20 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNIT VIAL 9/1/2010 12/31/2010 E0100026-0372-30 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 500 UNIT VIAL 9/1/2010 12/31/2010 E0100026-0372-50 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 9/1/2010 12/31/2010 E0100026-0379-20 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNITS VIAL 9/1/2010 12/31/2010 E0100026-0379-30 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 500 UNITS VIAL 9/1/2010 12/31/2010 E0100026-0379-50 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 9/1/2010 12/31/2010 E0100026-3786-60 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 2,000 UNIT VIAL 9/1/2010 99/99/9999 E0100026-3796-60 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 2,000 UNIT VIAL 9/1/2010 99/99/9999 E0100053-8130-01 J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 250 UNIT VIAL 9/1/2010 12/15/2011 E01

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00053-8130-02 J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 500 UNIT VIAL 9/1/2010 2/17/2012 E0100053-8130-04 J7192 FACTOR VIII, RECOMBINANT, PER IU HELIXATE FS 1,000 UNIT VIAL 9/1/2010 2/24/2012 E0100944-2831-10 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 220-400 UNIT VIAL 9/1/2010 11/2/2012 E0100944-2832-10 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 401-800 UNIT VIAL 9/1/2010 4/26/2013 E0100944-2833-10 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 801-1,240 UNIT VL 9/1/2010 4/26/2013 E0100944-2938-01 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 220-400 UNIT VL 9/1/2010 12/31/2010 E0100944-2938-02 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 401-800 UNIT VL 9/1/2010 12/31/2010 E0100944-2938-03 J7192 FACTOR VIII, RECOMBINANT, PER IU RECOMBINATE 801-1,240 UNITS VL 9/1/2010 12/31/2010 E0100944-2941-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 200-400 UNITS VIAL 9/1/2010 99/99/9999 E0100944-2942-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 401-800 UNITS VIAL 9/1/2010 99/99/9999 E0100944-2943-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 801-1,200 UNITS VIAL 9/1/2010 99/99/9999 E0100944-2944-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,201-1,800 UNITS VIAL 9/1/2010 99/99/9999 E0100944-2945-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 1,801-2,400 UNITS VIAL 9/1/2010 99/99/9999 E0100944-2946-10 J7192 FACTOR VIII, RECOMBINANT, PER IU ADVATE 2,401-3,600 UNITS VIAL 9/1/2010 99/99/9999 E0100026-3782-20 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 250 UNIT VIAL 9/1/2010 99/99/9999 E0100026-3785-50 J7192 FACTOR VIII, RECOMBINANT, PER IU KOGENATE FS 1,000 UNITS VIAL 9/1/2010 99/99/9999 E0100053-7668-02 J7193 FACTOR IX MONONINE 500 UNITS VIAL 9/1/2010 12/31/2010 E0100053-7668-04 J7193 FACTOR IX MONONINE 1,000 UNITS KIT 9/1/2010 1/7/2013 E0168516-3600-02 J7193 FACTOR IX ALPHANINE SD 250-1,500 UNIT VL 9/1/2010 3/31/2011 E0164193-0244-02 J7194 FACTOR IX, COMPLEX, HEAT-TREATED, PER UN BEBULIN VH IMMU 200-1,200 UNIT 9/1/2010 9/30/2012 E0168516-3200-02 J7194 FACTOR IX, COMPLEX, HEAT-TREATED, PER UN PROFILNINE SD 500 UNITS VIAL 9/1/2010 12/9/2010 E0168516-3200-03 J7194 FACTOR IX, COMPLEX, HEAT-TREATED, PER UN PROFILNINE SD 1,000-1,500 UNIT 9/1/2010 12/31/2010 E0158394-0001-01 J7195 FACTOR IX BENEFIX 1,000 UNIT VIAL 9/1/2010 11/30/2011 E0158394-0001-06 J7195 FACTOR IX BENEFIX 1,000 UNIT VIAL 9/1/2010 12/31/2013 E0158394-0002-01 J7195 FACTOR IX BENEFIX 500 UNIT VIAL 9/1/2010 9/30/2011 E0158394-0002-06 J7195 FACTOR IX BENEFIX 500 UNIT VIAL 9/1/2010 12/31/2013 E0158394-0003-01 J7195 FACTOR IX BENEFIX 250 UNIT VIAL 9/1/2010 9/30/2011 E0158394-0003-06 J7195 FACTOR IX BENEFIX 250 UNIT VIAL 9/1/2010 4/30/2013 E0158394-0008-02 J7195 FACTOR IX BENEFIX 2,000 UNIT VIAL 9/1/2010 12/31/2013 E0113533-0603-20 J7197 ANTITHROMBIN III (HUMAN), PER I.U. THROMBATE III 500 UNITS VIAL 9/1/2010 99/99/9999 E0113533-0603-30 J7197 ANTITHROMBIN III (HUMAN), PER I.U. THROMBATE III 1,000 UNITS VIAL 9/1/2010 9/30/2011 E0164193-0222-03 J7198 ANTI-HIBITOR, PER I.U. FEIBA VH IMMUNO 400-650 UNITS 9/1/2010 12/31/2012 E0164193-0222-04 J7198 ANTI-HIBITOR, PER I.U. FEIBA VH IMMUNO 651-1,200 UNIT 9/1/2010 12/31/2012 E0164193-0222-05 J7198 ANTI-HIBITOR, PER I.U. FEIBA VH IMMU 1,750-3,250 UNIT 9/1/2010 9/30/2011 E0150419-0421-01 J7302 LEVONORGESTREL-RELEASING INTRAUTERINE CO MIRENA SYSTEM 9/1/2010 99/99/9999 E0100052-0272-01 J7307 ETONOGESTREL IMPLANT SYSTEM IMPLANON 68 MG IMPLANT 9/1/2010 99/99/9999 E0124208-0412-01 J7310 GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT VITRASERT 4.5 MG IMPLANT 9/1/2010 99/99/9999 E0124208-0416-01 J7311 FLUOCINOLONE ACETONIDE, INTRAVITREAL IMP RETISERT IMPLANT 9/1/2010 99/99/9999 E0100054-4084-25 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZATHIOPRINE 50 MG TABLET 9/1/2010 99/99/9999 E0100054-8084-25 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZATHIOPRINE 50 MG TABLET 9/1/2010 99/99/9999 E0100406-2003-01 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZATHIOPRINE 50 MG TABLET 9/1/2010 6/30/2014 E0100781-5075-01 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZATHIOPRINE 50 MG TABLET 9/1/2010 9/30/2011 E0165483-0590-10 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG IMURAN 50 MG TABLET 9/1/2010 99/99/9999 E0165649-0231-41 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZASAN 75 MG TABLET 9/1/2010 99/99/9999 E0165649-0241-41 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZASAN 100 MG TABLET 9/1/2010 99/99/9999 E0166479-0301-10 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZATHIOPRINE 50 MG TABLET 9/1/2010 2/28/2011 E0168382-0003-01 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZATHIOPRINE 50 MG TABLET 9/1/2010 99/99/9999 E0168382-0003-05 J7500 AZATHIOPRINE - ORAL, TAB, 50 MG AZATHIOPRINE 50 MG TABLET 9/1/2010 99/99/9999 E0151552-0779-02 J7501 AZATHIOPRINE - PARENTERAL, VIAL, 100 MG. AZATHIOPRINE POWDER 9/1/2010 3/31/2011 E0151552-0779-04 J7501 AZATHIOPRINE - PARENTERAL, VIAL, 100 MG. AZATHIOPRINE POWDER 9/1/2010 3/31/2011 E0151552-0779-05 J7501 AZATHIOPRINE - PARENTERAL, VIAL, 100 MG. AZATHIOPRINE POWDER 9/1/2010 3/31/2011 E0155390-0600-20 J7501 AZATHIOPRINE - PARENTERAL, VIAL, 100 MG. AZATHIOPRINE SOD 100 MG VIAL 9/1/2010 8/31/2013 E0138779-0312-06 J7501 AZATHIOPRINE - PARENTERAL, VIAL, 100 MG. AZATHIOPRINE POWDER 9/1/2010 3/31/2011 E0138779-0312-03 J7501 AZATHIOPRINE - PARENTERAL, VIAL, 100 MG. AZATHIOPRINE POWDER 9/1/2010 3/31/2011 E0138779-0312-04 J7501 AZATHIOPRINE - PARENTERAL, VIAL, 100 MG. AZATHIOPRINE POWDER 9/1/2010 3/31/2011 E0100074-6479-32 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 GENGRAF 100 MG CAPSULE 9/1/2010 99/99/9999 E0100074-7269-50 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 GENGRAF 100 MG/ML SOLUTION 9/1/2010 99/99/9999 E0100078-0110-22 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 SANDIMMUNE 100 MG/ML SOLN 9/1/2010 99/99/9999 E0100078-0241-15 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 SANDIMMUNE 100 MG CAPSULE 9/1/2010 99/99/9999 E0100078-0248-15 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 NEORAL 100 MG GELATIN CAPSULE 9/1/2010 99/99/9999 E0100078-0274-22 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 NEORAL 100 MG/ML SOLUTION 9/1/2010 99/99/9999 E0100172-7312-46 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE MODIFIED 100 MG 9/1/2010 99/99/9999 E0100172-7313-20 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE 100 MG/ML SOLN 9/1/2010 99/99/9999 E0100185-0933-30 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE MODIFIED 100 MG 9/1/2010 99/99/9999 E0150111-0920-43 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE 100 MG SOFTGEL 9/1/2010 12/31/2011 E0160432-0140-50 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE 100 MG/ML SOLN 9/1/2010 2/29/2012 E0160505-0134-00 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE 100 MG CAPSULE 9/1/2010 99/99/9999 E0160505-0354-01 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE 100 MG/ML SOLN 9/1/2010 99/99/9999 E0162584-0827-21 J7502 CYCLOSPORINE - ORAL, SOL; 100 MG/ML, 50 CYCLOSPORINE 100 MG CAPSULE 9/1/2010 3/31/2011 E0100009-7224-02 J7504 LYMPHOCYTE IMMUNE GLOBULIN, ANTITYMOCYTE ATGAM 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0159676-0101-01 J7505 MUROMONAB-CD3, PARENTERAL, 5MG ORTHOCLONE OKT-3 5 MG/5 ML 9/1/2010 7/31/2011 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00054-0017-20 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100054-0017-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100054-0017-29 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100054-0018-20 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100054-0018-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100054-0018-29 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100054-0019-20 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 50 MG TABLET 9/1/2010 99/99/9999 E0100054-0019-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 50 MG TABLET 9/1/2010 99/99/9999 E0100054-3721-44 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG/ML SOLUTION 9/1/2010 99/99/9999 E0100054-3722-50 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG/5 ML SOLUTION 9/1/2010 99/99/9999 E0100054-3722-63 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG/5 ML SOLUTION 9/1/2010 99/99/9999 E0100054-4728-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100054-4728-31 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100054-4741-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 99/99/9999 E0100054-4741-31 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 99/99/9999 E0100054-4742-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 2.5 MG TABLET 9/1/2010 99/99/9999 E0100054-8722-16 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG/5 ML SOLUTION 9/1/2010 99/99/9999 E0100054-8724-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100054-8739-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 99/99/9999 E0100054-8740-25 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 2.5 MG TABLET 9/1/2010 99/99/9999 E0100143-1425-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 2.5 MG TABLET 9/1/2010 99/99/9999 E0100143-1473-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100143-1473-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100143-1475-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100143-1475-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100143-1477-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100143-1477-05 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100143-1477-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100259-0364-21 J7506 PREDNISONE, ORAL, PER 5 MG STERAPRED DS 10 MG TB UNIPAK 9/1/2010 12/31/2010 E0100259-0389-48 J7506 PREDNISONE, ORAL, PER 5 MG STERAPRED DS 10 MG TB UNIPAK 9/1/2010 12/31/2010 E0100259-0390-21 J7506 PREDNISONE, ORAL, PER 5 MG STERAPRED 5 MG TABLET UNIPAK 9/1/2010 12/31/2010 E0100259-0391-48 J7506 PREDNISONE, ORAL, PER 5 MG STERAPRED 5 MG TABLET UNIPAK 9/1/2010 12/31/2010 E0100591-5052-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100591-5052-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100591-5442-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100591-5442-05 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100591-5442-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100591-5443-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100591-5443-05 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100591-5443-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100603-5335-21 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 99/99/9999 E0100603-5335-32 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 99/99/9999 E0100603-5336-21 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 2.5 MG TABLET 9/1/2010 99/99/9999 E0100603-5337-15 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100603-5337-21 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100603-5337-31 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100603-5337-32 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0100603-5338-15 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TAB DOSE PACK 9/1/2010 99/99/9999 E0100603-5338-21 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100603-5338-28 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100603-5338-31 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TAB DOSE PACK 9/1/2010 99/99/9999 E0100603-5338-32 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0100603-5339-21 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100603-5339-28 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0100603-5339-32 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0110768-7283-04 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 11/1/2010 E0110768-7733-04 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 11/1/2010 E0145802-0303-21 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 6/1/2014 E0145802-0303-67 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 6/1/2014 E0145802-0733-21 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 3/1/2014 E0145802-0733-67 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 3/1/2014 E0151079-0022-19 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 12/31/2011 E0151079-0032-19 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 11/30/2011 E0151079-0033-19 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 8/31/2011 E0151552-0028-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE POWDER 9/1/2010 3/31/2011 E0151552-0028-02 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE POWDER 9/1/2010 3/31/2011 E0151552-0028-04 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE POWDER 9/1/2010 3/31/2011 E0151552-0028-05 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE POWDER 9/1/2010 3/31/2011 E0151991-0458-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 3/31/2013 E0153489-0138-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 12/31/2011 E0153489-0138-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 3/31/2012 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

53489-0139-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 4/30/2012 E0153489-0139-05 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 4/30/2012 E0153489-0139-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 12/31/2011 E0153489-0140-01 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 4/30/2012 E0153489-0140-05 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 4/30/2012 E0153489-0140-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 12/31/2011 E0159746-0171-06 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 99/99/9999 E0159746-0171-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 1 MG TABLET 9/1/2010 99/99/9999 E0159746-0172-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 99/99/9999 E0159746-0173-06 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0159746-0173-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 99/99/9999 E0159746-0175-09 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 99/99/9999 E0163739-0207-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 5 MG TABLET 9/1/2010 4/30/2012 E0163739-0208-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 10 MG TABLET 9/1/2010 3/31/2012 E0163739-0209-10 J7506 PREDNISONE, ORAL, PER 5 MG PREDNISONE 20 MG TABLET 9/1/2010 12/31/2011 E0100469-0607-73 J7507 TACROLIMUS, ORAL, PER 1 MG PROGRAF 0.5 MG CAPSULE 9/1/2010 99/99/9999 E0100469-0617-11 J7507 TACROLIMUS, ORAL, PER 1 MG PROGRAF 1 MG CAPSULE 9/1/2010 99/99/9999 E0100469-0617-73 J7507 TACROLIMUS, ORAL, PER 1 MG PROGRAF 1 MG CAPSULE 9/1/2010 99/99/9999 E0100469-0657-11 J7507 TACROLIMUS, ORAL, PER 1 MG PROGRAF 5 MG CAPSULE 9/1/2010 99/99/9999 E0100469-0657-73 J7507 TACROLIMUS, ORAL, PER 1 MG PROGRAF 5 MG CAPSULE 9/1/2010 99/99/9999 E0100009-0022-01 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG MEDROL 8 MG TABLET 9/1/2010 99/99/9999 E0100009-0049-02 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG MEDROL 2 MG TABLET 9/1/2010 5/24/2015 E0100009-0056-02 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG MEDROL 4 MG TABLET 9/1/2010 99/99/9999 E0100009-0056-04 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG MEDROL 4 MG DOSEPAK 9/1/2010 99/99/9999 E0100009-0073-01 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG MEDROL 16 MG TABLET 9/1/2010 99/99/9999 E0100009-0176-01 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG MEDROL 32 MG TABLET 9/1/2010 99/99/9999 E0100555-0301-02 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG TABLET 9/1/2010 2/29/2012 E0100555-0301-38 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG DOSEPK 9/1/2010 7/31/2012 E0100603-4593-15 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG DOSEPK 9/1/2010 99/99/9999 E0100603-4593-21 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG TABLET 9/1/2010 99/99/9999 E0100781-5022-01 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG TABLET 9/1/2010 99/99/9999 E0100781-5022-07 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG DOSEPK 9/1/2010 99/99/9999 E0151552-0603-02 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE POWDER 9/1/2010 3/31/2011 E0151991-0188-31 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG DOSEPK 9/1/2010 99/99/9999 E0159746-0001-03 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG DOSEPK 9/1/2010 99/99/9999 E0159746-0001-06 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG TABLET 9/1/2010 99/99/9999 E0159746-0001-09 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG TAB 9/1/2010 99/99/9999 E0159746-0002-04 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 8 MG TAB 9/1/2010 99/99/9999 E0159746-0003-14 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 16 MG TAB 9/1/2010 99/99/9999 E0159746-0015-04 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 32 MG TAB 9/1/2010 99/99/9999 E0163739-0161-10 J7509 METHYLPREDNISOLONE ORAL, PER 4 MG METHYLPREDNISOLONE 4 MG TABLET 9/1/2010 6/30/2012 E0100093-6118-16 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SOLN 9/1/2010 99/99/9999 E0100093-6118-87 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SOLN 9/1/2010 99/99/9999 E0100121-0759-08 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SOLN 9/1/2010 99/99/9999 E0100472-0212-08 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SYR 9/1/2010 9/30/2013 E0100472-0212-16 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SYR 9/1/2010 9/30/2013 E0100603-1567-56 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SYRUP 9/1/2010 99/99/9999 E0100603-1567-58 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SYRUP 9/1/2010 99/99/9999 E0150383-0040-04 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 5 MG/5 ML SOLN 9/1/2010 99/99/9999 E0150383-0042-24 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SOLN 9/1/2010 99/99/9999 E0150383-0042-48 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SOLN 9/1/2010 99/99/9999 E0151552-0026-02 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ANHYDROUS POWDER 9/1/2010 3/31/2011 E0151552-0026-04 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ANHYDROUS POWDER 9/1/2010 3/31/2011 E0151552-0026-05 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE ANHYDROUS POWDER 9/1/2010 3/31/2011 E0153014-0250-01 J7510 PREDNISOLONE ORAL, PER 5 MG PEDIAPRED 6.7 MG/5 ML SOLN 9/1/2010 12/31/2013 E0158177-0912-03 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 5 MG/5 ML SYRUP 9/1/2010 11/30/2010 E0158177-0932-05 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SOLN 9/1/2010 12/31/2010 E0160432-0212-08 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 15 MG/5 ML SOLN 9/1/2010 99/99/9999 E0165580-0251-01 J7510 PREDNISOLONE ORAL, PER 5 MG PREDNISOLONE 6.7 MG/5 ML SOLN 9/1/2010 3/13/2013 E0168135-0455-03 J7510 PREDNISOLONE ORAL, PER 5 MG ORAPRED 15 MG/5 ML SOLUTION 9/1/2010 99/99/9999 E0158468-0080-01 J7511 LYMPHOCYTE IMMUNE GLOBULIN THYMOGLOBULIN 25 MG VIAL 9/1/2010 99/99/9999 E0100004-0501-09 J7513 DACLIZUMAB, PARENTERAL, 25 MG ZENAPAX 5 MG/ML VIAL 9/1/2010 9/30/2011 E0100074-6463-32 J7515 ORAL, CYCLOSPORINE, 25 MG GENGRAF 25 MG CAPSULE 9/1/2010 99/99/9999 E0100078-0240-15 J7515 ORAL, CYCLOSPORINE, 25 MG SANDIMMUNE 25 MG CAPSULE 9/1/2010 99/99/9999 E0100078-0246-15 J7515 ORAL, CYCLOSPORINE, 25 MG NEORAL 25 MG GELATIN CAPSULE 9/1/2010 99/99/9999 E0100172-7310-46 J7515 ORAL, CYCLOSPORINE, 25 MG CYCLOSPORINE MODIFIED 25 MG 9/1/2010 99/99/9999 E0100172-7311-46 J7515 ORAL, CYCLOSPORINE, 25 MG CYCLOSPORINE MODIFIED 50 MG 9/1/2010 99/99/9999 E0100185-0932-30 J7515 ORAL, CYCLOSPORINE, 25 MG CYCLOSPORINE MODIFIED 25 MG 9/1/2010 99/99/9999 E0150111-0909-43 J7515 ORAL, CYCLOSPORINE, 25 MG CYCLOSPORINE 25 MG SOFTGEL 9/1/2010 9/30/2010 E0160505-0133-00 J7515 ORAL, CYCLOSPORINE, 25 MG CYCLOSPORINE 25 MG CAPSULE 9/1/2010 99/99/9999 E0100078-0109-01 J7516 CYCLOSPORINE, PARENTERAL, 250 MG SANDIMMUNE 50 MG/ML AMPUL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00574-0866-10 J7516 CYCLOSPORINE, PARENTERAL, 250 MG CYCLOSPORINE 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0151552-0663-01 J7516 CYCLOSPORINE, PARENTERAL, 250 MG CYCLOSPORINE POWDER 9/1/2010 3/31/2011 E0155390-0122-10 J7516 CYCLOSPORINE, PARENTERAL, 250 MG CYCLOSPORINE 50 MG/ML VIAL 9/1/2010 3/31/2014 E0100004-0259-01 J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG CELLCEPT 250 MG CAPSULE 9/1/2010 99/99/9999 E0100004-0259-05 J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG CELLCEPT 250 MG CAPSULE 9/1/2010 99/99/9999 E0100004-0259-43 J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG CELLCEPT 250 MG CAPSULE 9/1/2010 99/99/9999 E0100004-0260-01 J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG CELLCEPT 500 MG TABLET 9/1/2010 99/99/9999 E0100004-0260-43 J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG CELLCEPT 500 MG TABLET 9/1/2010 99/99/9999 E0100004-0261-29 J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG CELLCEPT 200 MG/ML ORAL SUSP 9/1/2010 99/99/9999 E0100078-0385-66 J7518 MYCOPHENOLIC ACID, ORAL, 180 MG MYFORTIC 180 MG TABLET 9/1/2010 99/99/9999 E0100078-0386-66 J7518 MYCOPHENOLIC ACID, ORAL, 180 MG MYFORTIC 360 MG TABLET 9/1/2010 99/99/9999 E0100008-1030-06 J7520 SIROLIMUS, ORAL, 1 MG RAPAMUNE 1 MG/ML ORAL SOLN 9/1/2010 99/99/9999 E0100008-1041-05 J7520 SIROLIMUS, ORAL, 1 MG RAPAMUNE 1 MG TABLET 9/1/2010 99/99/9999 E0100008-1041-10 J7520 SIROLIMUS, ORAL, 1 MG RAPAMUNE 1 MG TABLET 9/1/2010 99/99/9999 E0100008-1042-05 J7520 SIROLIMUS, ORAL, 1 MG RAPAMUNE 2 MG TABLET 9/1/2010 99/99/9999 E0100469-3016-01 J7525 TACROLIMUS, PARENTERAL, 5MG PROGRAF 5 MG/ML AMPULE 9/1/2010 99/99/9999 E0100078-0385-66 J7599 IMMUNOSUPPRESSIVE DRUG, NOC MYFORTIC 180 MG TABLET 9/1/2010 99/99/9999 E0100078-0386-66 J7599 IMMUNOSUPPRESSIVE DRUG, NOC MYFORTIC 360 MG TABLET 9/1/2010 99/99/9999 E0151552-0201-04 J7604 ACETYLCYSTEINE COMP UNIT ACETYLCYSTEINE POWDER 9/1/2010 3/31/2011 E0151552-0201-05 J7604 ACETYLCYSTEINE COMP UNIT ACETYLCYSTEINE POWDER 9/1/2010 3/31/2011 E0151552-0201-07 J7604 ACETYLCYSTEINE COMP UNIT ACETYLCYSTEINE POWDER 9/1/2010 3/31/2011 E0163402-0911-30 J7605 ARFORMOTEROL NON-COMP UNIT BROVANA 15 MCG/2 ML SOLUTION 9/1/2010 99/99/9999 E0100054-3025-02 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 10% VIAL 9/1/2010 10/31/2014 E0100054-3026-02 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 20% VIAL 9/1/2010 11/30/2014 E0100054-3027-02 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 10% VIAL 9/1/2010 5/31/2016 E0100054-3028-02 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 20% VIAL 9/1/2010 5/31/2016 E0100409-3307-03 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 10% VIAL 9/1/2010 99/99/9999 E0100409-3308-03 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 20% VIAL 9/1/2010 99/99/9999 E0100517-7504-25 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 10% VIAL 9/1/2010 99/99/9999 E0100517-7510-03 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 10% VIAL 9/1/2010 99/99/9999 E0100517-7604-25 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 20% VIAL 9/1/2010 99/99/9999 E0100517-7610-03 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 20% VIAL 9/1/2010 99/99/9999 E0100517-7630-03 J7608 ACETYLCYSTEINE NON-COMP UNIT ACETYLCYSTEINE 20% VIAL 9/1/2010 99/99/9999 E0151552-0044-02 J7609 ALBUTEROL, INHALATION SOL, 1 MG ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0044-04 J7609 ALBUTEROL, INHALATION SOL, 1 MG ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0044-05 J7609 ALBUTEROL, INHALATION SOL, 1 MG ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0044-07 J7609 ALBUTEROL, INHALATION SOL, 1 MG ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0044-02 J7613 ALBUTEROL, INHALATION SOLUTION ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0044-04 J7613 ALBUTEROL, INHALATION SOLUTION ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0044-05 J7613 ALBUTEROL, INHALATION SOLUTION ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0044-07 J7613 ALBUTEROL, INHALATION SOLUTION ALBUTEROL SULFATE POWDER 9/1/2010 3/31/2011 E0100185-7322-30 J7620 ALBUTEROL, UP TO 2.5 MG IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 9/1/2010 99/99/9999 E0100185-7322-60 J7620 ALBUTEROL, UP TO 2.5 MG IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 9/1/2010 99/99/9999 E0149502-0672-30 J7620 ALBUTEROL, UP TO 2.5 MG DUONEB 0.5 MG-3 MG/3 ML SOLN 9/1/2010 4/30/2014 E0149502-0672-60 J7620 ALBUTEROL, UP TO 2.5 MG DUONEB 0.5 MG-3 MG/3 ML SOLN 9/1/2010 6/30/2014 E0151552-0064-01 J7624 BETAMETHASONE INHALATION SOLUTION BETAMETHASONE SOD PHOS POWDER 9/1/2010 3/31/2011 E0151552-0064-02 J7624 BETAMETHASONE INHALATION SOLUTION BETAMETHASONE SOD PHOS POWDER 9/1/2010 3/31/2011 E0151552-0064-05 J7624 BETAMETHASONE INHALATION SOLUTION BETAMETHASONE SOD PHOS POWDER 9/1/2010 3/31/2011 E0100186-1988-04 J7626 BUDESONIDE INHALATION SOLUTION PULMICORT 0.25 MG/2 ML RESPUL 9/1/2010 99/99/9999 E0100186-1989-04 J7626 BUDESONIDE INHALATION SOLUTION PULMICORT 0.5 MG/2 ML RESPULE 9/1/2010 99/99/9999 E0100186-1990-04 J7626 BUDESONIDE INHALATION SOLUTION PULMICORT 1 MG/2 ML RESPULE 9/1/2010 99/99/9999 E0151552-0668-01 J7626 BUDESONIDE INHALATION SOLUTION BUDESONIDE POWDER 9/1/2010 3/31/2011 E0151552-0668-01 J7627 BUDESONIDE, INHALATION SOLUTION BUDESONIDE POWDER 9/1/2010 3/31/2011 E0100172-6406-49 J7631 CROMOLYN SODIUM NONCOMP UNIT CROMOLYN 20 MG/2 ML NEB SOLN 9/1/2010 99/99/9999 E0100172-6406-59 J7631 CROMOLYN SODIUM NONCOMP UNIT CROMOLYN 20 MG/2 ML NEB SOLN 9/1/2010 99/99/9999 E0100472-0750-21 J7631 CROMOLYN SODIUM NONCOMP UNIT CROMOLYN NEBULIZER SOLUTION 9/1/2010 12/31/2012 E0100472-0750-60 J7631 CROMOLYN SODIUM NONCOMP UNIT CROMOLYN NEBULIZER SOLUTION 9/1/2010 6/30/2014 E0100472-0752-21 J7631 CROMOLYN SODIUM NONCOMP UNIT CROMOLYN NEBULIZER SOLUTION 9/1/2010 12/31/2012 E0100472-0752-60 J7631 CROMOLYN SODIUM NONCOMP UNIT CROMOLYN NEBULIZER SOLUTION 9/1/2010 12/31/2012 E0151552-0423-02 J7632 CROMOLYN SODIUM COMP UNIT CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0151552-0423-04 J7632 CROMOLYN SODIUM COMP UNIT CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0151552-0423-05 J7632 CROMOLYN SODIUM COMP UNIT CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0151552-0423-07 J7632 CROMOLYN SODIUM COMP UNIT CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0151552-0025-01 J7638 DEXAMETHASONE DEXAMETHASONE SOD PH POWDER 9/1/2010 3/31/2011 E0151552-0025-02 J7638 DEXAMETHASONE DEXAMETHASONE SOD PH POWDER 9/1/2010 3/31/2011 E0151552-0025-03 J7638 DEXAMETHASONE DEXAMETHASONE SOD PH POWDER 9/1/2010 3/31/2011 E0151552-0025-04 J7638 DEXAMETHASONE DEXAMETHASONE SOD PH POWDER 9/1/2010 3/31/2011 E0151552-0025-05 J7638 DEXAMETHASONE DEXAMETHASONE SOD PH POWDER 9/1/2010 3/31/2011 E0151552-0430-01 J7638 DEXAMETHASONE DEXAMETHASONE MICRONIZED POWD 9/1/2010 3/31/2011 E0151552-0430-02 J7638 DEXAMETHASONE DEXAMETHASONE MICRONIZED POWD 9/1/2010 3/31/2011 E0150242-0100-39 J7639 DORNASE INHAL SOL U D PULMOZYME 1 MG/ML AMPUL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

50242-0100-40 J7639 DORNASE INHAL SOL U D PULMOZYME 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-4601-25 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-4602-25 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-4605-25 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-4620-25 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0016-02 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 4/30/2014 E0110019-0016-17 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 3/31/2014 E0110019-0016-54 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 1/31/2014 E0110019-0016-81 J7643 GLYCOPYRROLATE GLYCOPYRROLATE 0.2 MG/ML VIAL 9/1/2010 3/31/2014 E0151552-0042-01 J7643 GLYCOPYRROLATE GLYCOPYRROLATE POWDER 9/1/2010 3/31/2011 E0160977-0155-01 J7643 GLYCOPYRROLATE ROBINUL 0.2 MG/ML VIAL 9/1/2010 3/31/2014 E0160977-0155-02 J7643 GLYCOPYRROLATE ROBINUL 0.2 MG/ML VIAL 9/1/2010 3/31/2014 E0160977-0155-03 J7643 GLYCOPYRROLATE ROBINUL 0.2 MG/ML VIAL 9/1/2010 1/31/2014 E0160977-0155-06 J7643 GLYCOPYRROLATE ROBINUL 0.2 MG/ML VIAL 9/1/2010 10/31/2013 E0100378-6989-66 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 2/28/2014 E0100472-0751-23 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 6/30/2014 E0100472-0751-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 12/31/2012 E0100472-0751-60 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 6/30/2014 E0100472-0753-23 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 9/30/2013 E0100472-0753-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 12/31/2012 E0100472-0753-60 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 9/30/2013 E0100487-9801-01 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 99/99/9999 E0100487-9801-02 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 99/99/9999 E0100487-9801-25 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 99/99/9999 E0100487-9801-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 99/99/9999 E0100487-9801-60 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 99/99/9999 E0116252-0098-22 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 11/30/2012 E0116252-0098-33 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 11/30/2012 E0116252-0098-66 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 3/31/2013 E0149502-0685-26 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 7/31/2011 E0149502-0685-30 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 12/31/2011 E0149502-0685-61 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 12/31/2012 E0151552-0393-01 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0151552-0393-02 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0151552-0393-04 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0151552-0393-05 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0149502-0685-62 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 12/31/2011 E0149502-0685-31 J7644 IPRATROPIUM BROMIDE, PER MG IPRATROPIUM BR 0.02% SOLN 9/1/2010 12/31/2011 E0151552-0393-01 J7645 IPRATROPIUM BROMIDE, INHALATION SOL IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0151552-0393-02 J7645 IPRATROPIUM BROMIDE, INHALATION SOL IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0151552-0393-04 J7645 IPRATROPIUM BROMIDE, INHALATION SOL IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0151552-0393-05 J7645 IPRATROPIUM BROMIDE, INHALATION SOL IPRATROPIUM BROMIDE POWDER 9/1/2010 3/31/2011 E0100409-1410-01 J7659 ISOPROTERENOL HCL ISUPREL 0.2 MG/ML AMPUL 9/1/2010 9/1/2014 E0100409-1410-05 J7659 ISOPROTERENOL HCL ISUPREL 0.2 MG/ML AMPUL 9/1/2010 2/1/2015 E0100409-1410-01 J7660 ISOPROTERENOL HCI, INHALATION SOL, P MIL ISUPREL 0.2 MG/ML AMPUL 9/1/2010 9/1/2014 E0100409-1410-05 J7660 ISOPROTERENOL HCI, INHALATION SOL, P MIL ISUPREL 0.2 MG/ML AMPUL 9/1/2010 2/1/2015 E0151552-0079-02 J7669 METAPROTERENOL SULFATE METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0079-04 J7669 METAPROTERENOL SULFATE METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0079-05 J7669 METAPROTERENOL SULFATE METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0079-07 J7669 METAPROTERENOL SULFATE METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0079-02 J7670 METAPROTERENOL SULFATE, PER 10 MILLIGRAM METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0079-04 J7670 METAPROTERENOL SULFATE, PER 10 MILLIGRAM METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0079-05 J7670 METAPROTERENOL SULFATE, PER 10 MILLIGRAM METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0079-07 J7670 METAPROTERENOL SULFATE, PER 10 MILLIGRAM METAPROTERENOL SULFATE POWDER 9/1/2010 3/31/2011 E0163323-0113-10 J7676 PENTAMIDINE ISETHIONATE, INHALATION SOLU PENTAM 300 VIAL 9/1/2010 99/99/9999 E0163323-0877-15 J7676 PENTAMIDINE ISETHIONATE, INHALATION SOLU NEBUPENT 300 MG INHAL POWDER 9/1/2010 99/99/9999 E0151552-0446-03 J7681 TERBUTALINE SULFATE TERBUTALINE SULFATE POWDER 9/1/2010 3/31/2011 E0151552-0446-04 J7681 TERBUTALINE SULFATE TERBUTALINE SULFATE POWDER 9/1/2010 3/31/2011 E0139822-0412-01 J7682 TOBRAMYCIN TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E0139822-0412-06 J7682 TOBRAMYCIN TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E0153905-0065-01 J7682 TOBRAMYCIN TOBI 300 MG/5 ML SOLUTION 9/1/2010 10/31/2010 E0163323-0303-51 J7682 TOBRAMYCIN TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E0163323-0303-55 J7682 TOBRAMYCIN TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E0139822-5300-05 J7684 TRIAMCINOLONE TRIAMCINOLONE ACETONIDE POWD 9/1/2010 2/28/2013 E0151552-0033-01 J7684 TRIAMCINOLONE TRIAMCINOLONE ACETONIDE POWDER 9/1/2010 3/31/2011 E0151552-0033-02 J7684 TRIAMCINOLONE TRIAMCINOLONE ACETONIDE POWDER 9/1/2010 3/31/2011 E0151552-0033-03 J7684 TRIAMCINOLONE TRIAMCINOLONE ACETONIDE POWDER 9/1/2010 3/31/2011 E0151552-0033-05 J7684 TRIAMCINOLONE TRIAMCINOLONE ACETONIDE POWDER 9/1/2010 3/31/2011 E0151552-0768-01 J7684 TRIAMCINOLONE TRIAMCINOLONE POWDER 9/1/2010 3/31/2011 E0139822-0412-01 J7685 TOBRAMYCIN, PER 300 MILLIGRAMS TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E0139822-0412-06 J7685 TOBRAMYCIN, PER 300 MILLIGRAMS TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

63323-0303-51 J7685 TOBRAMYCIN, PER 300 MILLIGRAMS TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E0163323-0303-55 J7685 TOBRAMYCIN, PER 300 MILLIGRAMS TOBRAMYCIN 1.2 GM VIAL 9/1/2010 99/99/9999 E0100085-1401-01 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE FORADIL AEROLIZER 12 MCG CAP 9/1/2010 99/99/9999 E0100085-1402-01 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE FORADIL AEROLIZER 12 MCG CAP 9/1/2010 99/99/9999 E0149502-0605-61 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE PERFOROMIST 20 MCG/2 ML SOLN 9/1/2010 99/99/9999 E0151552-0201-04 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE ACETYLCYSTEINE POWDER 9/1/2010 3/31/2011 E0151552-0201-05 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE ACETYLCYSTEINE POWDER 9/1/2010 3/31/2011 E0151552-0201-07 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE ACETYLCYSTEINE POWDER 9/1/2010 3/31/2011 E0151552-0423-02 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0151552-0423-04 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0151552-0423-05 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0151552-0423-07 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE CROMOLYN SODIUM POWDER 9/1/2010 3/31/2011 E0163323-0113-10 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE PENTAM 300 VIAL 9/1/2010 99/99/9999 E0163323-0877-15 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE NEBUPENT 300 MG INHAL POWDER 9/1/2010 99/99/9999 E0163402-0911-30 J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTE BROVANA 15 MCG/2 ML SOLUTION 9/1/2010 99/99/9999 E0100053-7596-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, VIVAGLOBIN 16% VIAL 9/1/2010 3/31/2011 E0100053-7596-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, VIVAGLOBIN 16% VIAL 9/1/2010 5/6/2013 E0100053-7596-15 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, VIVAGLOBIN 16% VIAL 9/1/2010 12/31/2010 E0100053-7596-20 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, VIVAGLOBIN 16% VIAL 9/1/2010 6/8/2013 E0100053-7596-25 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, VIVAGLOBIN 16% VIAL 9/1/2010 12/31/2010 E0100264-1129-50 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 70%-WATER IV SOLN 9/1/2010 9/30/2010 E0100264-1240-55 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 30%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-1280-50 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-1280-55 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER IV SOLN 9/1/2010 9/30/2014 E0100264-1290-50 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 70%-WATER IV SOLN 9/1/2010 5/31/2013 E0100264-1290-55 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 70%-WATER IV SOLN 9/1/2010 99/99/9999 E0100264-2303-50 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, RESECTISOL 5% SOLUTION 9/1/2010 99/99/9999 E0100264-4021-55 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 9/30/2015 E0100264-7520-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100264-7520-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100264-7578-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MANNITOL 20% IV SOLUTION 9/1/2010 99/99/9999 E0100264-7578-20 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MANNITOL 20% IV SOLUTION 9/1/2010 99/99/9999 E0100264-7605-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 2.5%-0.45% NACL IV 9/1/2010 99/99/9999 E0100264-7605-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 2.5%-0.45% NACL IV 9/1/2010 2/28/2014 E0100264-7612-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7612-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7612-20 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7614-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.33% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7614-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.33% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7616-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.2% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7616-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.2% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7616-20 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.2% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7622-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-0.45% NACL IV SOL 9/1/2010 99/99/9999 E0100264-7623-20 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-0.2% NACL IV SOLN 9/1/2010 99/99/9999 E0100264-7802-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SALINE 0.45% SOLN-EXCEL CON 9/1/2010 99/99/9999 E0100264-7802-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SALINE 0.45% SOLN-EXCEL CON 9/1/2010 99/99/9999 E0100264-7805-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 3% IV SOLN 9/1/2010 99/99/9999 E0100264-7806-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 5% IV SOLN 9/1/2010 99/99/9999 E0100338-0023-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100338-0023-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100338-0023-04 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100338-0031-06 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER IV SOLN 9/1/2010 12/31/2010 E0100338-0043-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100338-0043-04 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100338-0054-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 3% IV SOLN 9/1/2010 99/99/9999 E0100338-0056-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 5% IV SOLN 9/1/2010 99/99/9999 E0100338-0073-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 2.5%-1/2NS IV SOLN 9/1/2010 7/31/2011 E0100338-0073-04 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 2.5%-0.45% NACL IV 9/1/2010 99/99/9999 E0100338-0077-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.2% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0077-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.2% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0077-04 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.2% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0081-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.33% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0085-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0085-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0085-04 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100338-0351-04 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, OSMITROL 5% IV SOLUTION 9/1/2010 99/99/9999 E0100338-0353-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, OSMITROL 10% IV SOLUTION 9/1/2010 99/99/9999 E0100338-0355-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, OSMITROL 15% IV SOLUTION 9/1/2010 99/99/9999 E0100338-0357-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, OSMITROL 20% IV SOLUTION 9/1/2010 99/99/9999 E0100338-0357-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, OSMITROL 20% IV SOLUTION 9/1/2010 99/99/9999 E0100338-0719-06 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 70%-WATER IV SOLN 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00338-0719-13 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 70%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-1130-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 4 MEQ/ML VL 9/1/2010 99/99/9999 E0100409-1141-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 4 MEQ/ML VL 9/1/2010 99/99/9999 E0100409-1508-05 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 2.5%-WATER IV SOLN 9/1/2010 7/1/2011 E0100409-1534-05 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-0.9% NACL IV SOLN 9/1/2010 7/1/2011 E0100409-1535-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 20%-WATER IV SOLN 9/1/2010 9/30/2011 E0100409-1586-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 5% IV SOLN 9/1/2010 9/30/2011 E0100409-1775-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 25%-WATER SYRINGE 9/1/2010 99/99/9999 E0100409-4089-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10% AMPUL 9/1/2010 11/1/2012 E0100409-4219-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CL 2.5 MEQ/ML VIAL 9/1/2010 9/30/2011 E0100409-4862-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-1/4NS IV SOLN 9/1/2010 12/31/2013 E0100409-4862-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-1/4NS IV SOLN 9/1/2010 9/30/2011 E0100409-4902-34 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER ABBOJECT 9/1/2010 99/99/9999 E0100409-6648-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER VIAL 9/1/2010 99/99/9999 E0100409-6657-73 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CL 2.5 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100409-6660-75 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CL 2.5 MEQ/ML VIAL 9/1/2010 99/99/9999 E0100409-7119-07 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER IV SOLN 9/1/2010 9/30/2011 E0100409-7120-07 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 70%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7132-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-7132-66 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-7132-67 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-7517-16 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER SYRINGE 9/1/2010 99/99/9999 E0100409-7712-09 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MANNITOL 5% IV SOLUTION 9/1/2010 9/30/2011 E0100409-7713-09 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MANNITOL 10% IV SOLUTION 9/1/2010 9/30/2011 E0100409-7714-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MANNITOL 15% IV SOLUTION 9/1/2010 9/30/2011 E0100409-7715-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MANNITOL 20% IV SOLUTION 9/1/2010 99/99/9999 E0100409-7715-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MANNITOL 20% IV SOLUTION 9/1/2010 99/99/9999 E0100409-7730-20 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLUTION 9/1/2010 9/30/2011 E0100409-7730-36 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-7730-37 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-7918-19 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 70%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7924-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.225% NACL IV SOL 9/1/2010 99/99/9999 E0100409-7924-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.225% NACL IV SOL 9/1/2010 99/99/9999 E0100409-7924-09 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.225% NACL IV SOL 9/1/2010 99/99/9999 E0100409-7925-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.3% NACL IV SOLN 9/1/2010 4/1/2012 E0100409-7925-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.3% NACL IV SOLN 9/1/2010 99/99/9999 E0100409-7925-09 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.3% NACL IV SOLN 9/1/2010 99/99/9999 E0100409-7926-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100409-7926-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100409-7926-09 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 99/99/9999 E0100409-7926-30 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 5/1/2013 E0100409-7926-48 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 5%-0.45% NACL IV SOLN 9/1/2010 11/1/2013 E0100409-7930-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100409-7930-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100409-7930-09 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100409-7935-19 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 20%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7936-19 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7936-29 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER IV SOLN 9/1/2010 9/30/2011 E0100409-7937-19 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 40%-WATER IV SOLN 9/1/2010 99/99/9999 E0100409-7938-19 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 10%-WATER IV SOLUTION 9/1/2010 99/99/9999 E0100409-7985-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-7985-03 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-7985-09 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 0.45% SOLN 9/1/2010 99/99/9999 E0100409-8004-15 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 30%-WATER IV SOLN 9/1/2010 99/99/9999 E0100469-3250-10 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, MYCAMINE 50 MG VIAL 9/1/2010 99/99/9999 E0100517-2900-25 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 4 MEQ/ML VL 9/1/2010 1/31/2013 E0100517-2930-25 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 4 MEQ/ML VL 9/1/2010 99/99/9999 E0100548-1001-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER MINIJET 9/1/2010 3/31/2011 E0100548-2001-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER SYRINGE 9/1/2010 3/31/2011 E0100548-3301-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 50%-WATER SYRINGE 9/1/2010 9/30/2014 E0100548-3315-00 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, DEXTROSE 25%-WATER SYRINGE 9/1/2010 3/31/2011 E0151552-0232-02 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, PHENYLEPHRINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0232-04 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, PHENYLEPHRINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0232-05 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, PHENYLEPHRINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0526-05 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, EPINEPHRINE POWDER 9/1/2010 3/31/2011 E0163323-0088-61 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 4 MEQ/ML VL 9/1/2010 99/99/9999 E0163323-0088-63 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 4 MEQ/ML VL 9/1/2010 99/99/9999 E0163323-0139-20 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CL 2.5 MEQ/ML VIAL 9/1/2010 99/99/9999 E0163323-0139-40 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CL 2.5 MEQ/ML VIAL 9/1/2010 99/99/9999 E0163323-0187-30 J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, SODIUM CHLORIDE 4 MEQ/ML VL 9/1/2010 99/99/9999 E0100182-7100-11 J8498 ANTIEMETIC DRUG PROMETHAZINE 25 MG SUPPOSITORY 9/1/2010 3/31/2011 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00574-7226-12 J8498 ANTIEMETIC DRUG COMPRO 25 MG SUPPOSITORY 9/1/2010 99/99/9999 E0100574-7234-12 J8498 ANTIEMETIC DRUG PHENADOZ 25 MG SUPPOSITORY 9/1/2010 7/31/2014 E0100574-7236-12 J8498 ANTIEMETIC DRUG PHENADOZ 12.5 MG SUPPOSITORY 9/1/2010 7/31/2014 E0100713-0135-12 J8498 ANTIEMETIC DRUG PROCHLORPERAZINE 25 MG SUPP 9/1/2010 99/99/9999 E0100713-0526-12 J8498 ANTIEMETIC DRUG PROMETHEGAN 25 MG SUPP 9/1/2010 99/99/9999 E0100713-0536-12 J8498 ANTIEMETIC DRUG PROMETHEGAN 12.5 MG SUPPOS 9/1/2010 99/99/9999 E0145802-0758-30 J8498 ANTIEMETIC DRUG PROMETHAZINE 12.5 MG SUPPOS 9/1/2010 99/99/9999 E0145802-0759-30 J8498 ANTIEMETIC DRUG PROMETHAZINE 25 MG SUPPOSITORY 9/1/2010 99/99/9999 E0100093-8940-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 99/99/9999 E0100093-8940-05 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 99/99/9999 E0100093-8943-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0100093-8943-05 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0100093-8947-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 99/99/9999 E0100093-8947-05 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 99/99/9999 E0100173-0945-55 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ZOVIRAX 800 MG TABLET 9/1/2010 99/99/9999 E0100173-0949-55 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ZOVIRAX 400 MG TABLET 9/1/2010 6/12/2015 E0100173-0953-96 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ZOVIRAX 200 MG/5 ML SUSP 9/1/2010 99/99/9999 E0100173-0991-55 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ZOVIRAX 200 MG CAPSULE 9/1/2010 99/99/9999 E0100472-0082-16 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG/5 ML SUSP 9/1/2010 99/99/9999 E0100591-0335-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 10/31/2012 E0100591-0336-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 10/31/2012 E0100591-2692-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 5/31/2012 E0100904-5789-61 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 99/99/9999 E0100904-5790-61 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0100904-5799-61 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 7/31/2011 E0150383-0810-16 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG/5 ML SUSP 9/1/2010 99/99/9999 E0151079-0876-20 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 12/31/2011 E0151079-0877-20 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 2/29/2012 E0151079-0878-20 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 12/31/2011 E0160505-0042-06 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 99/99/9999 E0160505-5306-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0160505-5306-08 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0160505-5307-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 99/99/9999 E0160505-5307-05 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 99/99/9999 E0163304-0504-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0163304-0505-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 99/99/9999 E0163304-0652-01 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 99/99/9999 E0163304-0652-05 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 12/31/2011 E0167253-0100-10 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 99/99/9999 E0167253-0100-11 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 200 MG CAPSULE 9/1/2010 99/99/9999 E0167253-0101-10 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0167253-0101-11 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 400 MG TABLET 9/1/2010 99/99/9999 E0167253-0102-10 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 9/30/2011 E0167253-0102-50 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAP ACYCLOVIR 800 MG TABLET 9/1/2010 9/30/2011 E0100006-0461-06 J8501 APREPITANT, ORAL, 5 MG EMEND 80 MG CAPSULE 9/1/2010 99/99/9999 E0100006-0462-06 J8501 APREPITANT, ORAL, 5 MG EMEND 125 MG CAPSULE 9/1/2010 99/99/9999 E0100006-0464-05 J8501 APREPITANT, ORAL, 5 MG EMEND 40 MG CAPSULE 9/1/2010 99/99/9999 E0100006-0464-10 J8501 APREPITANT, ORAL, 5 MG EMEND 40 MG CAPSULE 9/1/2010 99/99/9999 E0100006-3862-03 J8501 APREPITANT, ORAL, 5 MG EMEND TRIFOLD PACK 9/1/2010 99/99/9999 E0100093-5420-88 J8515 CALBERGOLINE, ORAL, 0.25 MG CABERGOLINE 0.5 MG TABLET 9/1/2010 99/99/9999 E0149884-0673-14 J8515 CALBERGOLINE, ORAL, 0.25 MG CABERGOLINE 0.5 MG TABLET 9/1/2010 99/99/9999 E0100004-1100-20 J8520 CAPECITABINE, ORAL, 150 MG XELODA 150 MG TABLET 9/1/2010 99/99/9999 E0100004-1101-50 J8521 CAPECITABINE, ORAL, 500 MG XELODA 500 MG TABLET 9/1/2010 99/99/9999 E0100054-3176-44 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE INTENSOL 1MG/1ML 9/1/2010 99/99/9999 E0100054-4179-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 0.5 MG TABLET 9/1/2010 99/99/9999 E0100054-4180-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 0.75 MG TABLET 9/1/2010 99/99/9999 E0100054-4181-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 1 MG TABLET 9/1/2010 99/99/9999 E0100054-4182-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 1.5 MG TABLET 9/1/2010 99/99/9999 E0100054-4183-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 2 MG TABLET 9/1/2010 99/99/9999 E0100054-4184-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 4 MG TABLET 9/1/2010 99/99/9999 E0100054-8174-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 1 MG TABLET 9/1/2010 99/99/9999 E0100054-8175-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 4 MG TABLET 9/1/2010 99/99/9999 E0100054-8176-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 2 MG TABLET 9/1/2010 99/99/9999 E0100054-8179-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 0.5 MG TABLET 9/1/2010 99/99/9999 E0100054-8180-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 0.75 MG TABLET 9/1/2010 99/99/9999 E0100054-8181-25 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 1.5 MG TABLET 9/1/2010 99/99/9999 E0100095-0086-35 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXPAK 10 DAY 1.5 MG TABLET 9/1/2010 9/30/2011 E0100095-0086-51 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXPAK 13 DAY 1.5 MG TABLET 9/1/2010 9/30/2011 E0160432-0466-08 J8540 DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE 0.5 MG/5 ML ELX 9/1/2010 99/99/9999 E0100310-0482-30 J8565 GEFITINIB, ORAL, 250 MG IRESSA 250 MG TABLET 9/1/2010 99/99/9999 E0100187-0247-01 J8650 NABILONE, ORAL, 1 MG CESAMET 1 MG CAPSULE 9/1/2010 12/31/2012 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00003-6335-17 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI DROXIA 200 MG CAPSULE 9/1/2010 99/99/9999 E0100003-6336-17 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI DROXIA 300 MG CAPSULE 9/1/2010 99/99/9999 E0100003-6337-17 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI DROXIA 400 MG CAPSULE 9/1/2010 99/99/9999 E0100009-7663-04 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI AROMASIN 25 MG TABLET 9/1/2010 99/99/9999 E0100015-0508-42 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGACE 40 MG/ML ORAL SUSP 9/1/2010 99/99/9999 E0100015-3030-20 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI CEENU 10 MG CAPSULE 9/1/2010 4/15/2015 E0100015-3031-20 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI CEENU 40 MG CAPSULE 9/1/2010 4/15/2015 E0100015-3032-20 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI CEENU 100 MG CAPSULE 9/1/2010 6/30/2013 E0100054-3542-58 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 99/99/9999 E0100054-4581-11 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MERCAPTOPURINE 50 MG TABLET 9/1/2010 99/99/9999 E0100054-4581-27 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MERCAPTOPURINE 50 MG TABLET 9/1/2010 99/99/9999 E0100054-4603-25 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 20 MG TABLET 9/1/2010 99/99/9999 E0100054-4604-25 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0100054-8603-25 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 20 MG TABLET 9/1/2010 99/99/9999 E0100054-8604-25 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0100093-0782-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 20 MG TABLET 9/1/2010 99/99/9999 E0100093-0782-56 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 20 MG TABLET 9/1/2010 99/99/9999 E0100093-0784-06 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 10 MG TABLET 9/1/2010 99/99/9999 E0100093-0784-86 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 10 MG TABLET 9/1/2010 99/99/9999 E0100093-5510-06 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MERCAPTOPURINE 50 MG TABLET 9/1/2010 99/99/9999 E0100093-9634-87 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 8/31/2012 E0100121-4776-10 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 400 MG/10 ML 9/1/2010 99/99/9999 E0100172-4960-58 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI FLUTAMIDE 125 MG CAPSULE 9/1/2010 99/99/9999 E0100172-4960-70 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI FLUTAMIDE 125 MG CAPSULE 9/1/2010 99/99/9999 E0100173-0635-35 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI LEUKERAN 2 MG TABLET 9/1/2010 6/30/2014 E0100185-1125-05 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI FLUTAMIDE 125 MG CAPSULE 9/1/2010 12/31/2012 E0100185-1125-18 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI FLUTAMIDE 125 MG CAPSULE 9/1/2010 12/31/2012 E0100185-1125-88 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI FLUTAMIDE 125 MG CAPSULE 9/1/2010 12/31/2012 E0100310-0201-30 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI ARIMIDEX 1 MG TABLET 9/1/2010 99/99/9999 E0100378-0144-05 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 10 MG TABLET 9/1/2010 99/99/9999 E0100378-0144-91 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 10 MG TABLET 9/1/2010 99/99/9999 E0100378-0274-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 20 MG TABLET 9/1/2010 99/99/9999 E0100378-0274-93 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 20 MG TABLET 9/1/2010 99/99/9999 E0100378-3547-25 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MERCAPTOPURINE 50 MG TABLET 9/1/2010 99/99/9999 E0100378-3547-52 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MERCAPTOPURINE 50 MG TABLET 9/1/2010 99/99/9999 E0100555-0446-09 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 10 MG TABLET 9/1/2010 3/31/2011 E0100555-0446-63 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 10 MG TABLET 9/1/2010 11/30/2010 E0100555-0606-02 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 20 MG TABLET 9/1/2010 99/99/9999 E0100555-0607-02 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0100555-0607-04 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 12/31/2015 E0100555-0870-63 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI FLUTAMIDE 125 MG CAPSULE 9/1/2010 8/31/2011 E0100555-0882-02 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI HYDROXYUREA 500 MG CAPSULE 9/1/2010 99/99/9999 E0100555-0904-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 20 MG TABLET 9/1/2010 11/30/2011 E0100555-0904-14 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 20 MG TABLET 9/1/2010 9/30/2011 E0100904-3571-61 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0113632-0123-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI SOLTAMOX 10 MG/5 ML SOLN 9/1/2010 99/99/9999 E0149884-0289-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 20 MG TABLET 9/1/2010 99/99/9999 E0149884-0290-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0149884-0290-04 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0149884-0290-05 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0149884-0724-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI HYDROXYUREA 500 MG CAPSULE 9/1/2010 99/99/9999 E0149884-0753-13 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI FLUTAMIDE 125 MG CAPSULE 9/1/2010 99/99/9999 E0149884-0907-38 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 99/99/9999 E0149884-0907-61 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 99/99/9999 E0149884-0922-02 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MERCAPTOPURINE 50 MG TABLET 9/1/2010 99/99/9999 E0149884-0922-04 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MERCAPTOPURINE 50 MG TABLET 9/1/2010 99/99/9999 E0151079-0434-20 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 20 MG TABLET 9/1/2010 99/99/9999 E0151079-0435-20 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0154482-0053-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MATULANE 50 MG CAPSULE 9/1/2010 99/99/9999 E0157844-0522-06 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI PURINETHOL 50 MG TABLET 9/1/2010 99/99/9999 E0160432-0126-08 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 99/99/9999 E0160432-0126-16 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 99/99/9999 E0160505-0368-01 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 99/99/9999 E0163739-0165-10 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL 40 MG TABLET 9/1/2010 99/99/9999 E0163739-0269-10 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI TAMOXIFEN 10 MG TABLET 9/1/2010 99/99/9999 E0168094-0518-62 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 40 MG/ML SUSP 9/1/2010 99/99/9999 E0168094-0528-61 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 400 MG/10 ML 9/1/2010 99/99/9999 E0168094-0528-62 J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTI MEGESTROL ACET 400 MG/10 ML 9/1/2010 99/99/9999 E0100703-5040-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 9/1/2010 99/99/9999 E0100703-5043-03 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100703-5046-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 9/1/2010 99/99/9999 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

55390-0231-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG ADRIAMYCIN 10 MG VIAL 9/1/2010 6/30/2014 E0155390-0232-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG ADRIAMYCIN 20 MG VIAL 9/1/2010 6/30/2014 E0155390-0233-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG ADRIAMYCIN 50 MG VIAL 9/1/2010 5/31/2014 E0155390-0235-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG ADRIAMYCIN 2 MG/ML VIAL 9/1/2010 11/30/2012 E0155390-0236-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG ADRIAMYCIN 2 MG/ML VIAL 9/1/2010 1/31/2013 E0155390-0237-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG ADRIAMYCIN 2 MG/ML VIAL 9/1/2010 1/31/2013 E0155390-0238-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG ADRIAMYCIN 200 MG/100 ML VIAL 9/1/2010 1/31/2013 E0155390-0241-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 10 MG VIAL 9/1/2010 6/30/2014 E0155390-0243-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 50 MG VIAL 9/1/2010 5/31/2014 E0155390-0245-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 9/1/2010 9/30/2012 E0155390-0246-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 20 MG/10 ML VIAL 9/1/2010 1/31/2013 E0155390-0247-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 9/1/2010 1/31/2013 E0155390-0248-01 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 9/1/2010 11/30/2012 E0163323-0101-61 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 200 MG/100 ML VIAL 9/1/2010 99/99/9999 E0163323-0883-05 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 10 MG/5 ML VIAL 9/1/2010 99/99/9999 E0163323-0883-10 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 20 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0883-30 J9000 DOXORUBICIN HYDROCHLORIDE, 10 MG DOXORUBICIN 50 MG/25 ML VIAL 9/1/2010 99/99/9999 E0117314-9600-01 J9001 DOXORUBICIN HCL DOXIL 2 MG/ML VIAL 9/1/2010 6/1/2012 E0117314-9600-02 J9001 DOXORUBICIN HCL DOXIL 2 MG/ML VIAL 9/1/2010 6/1/2012 E0150419-0357-03 J9010 ALEMTUZUMAB CAMPATH 30 MG/ML VIAL 9/1/2010 9/30/2011 E0100078-0495-61 J9015 ALDESLEUKIN PROLEUKIN 22 MILLION UNIT VIAL 9/1/2010 3/31/2012 E0163459-0600-10 J9017 ARSENIC TRIOXIDE TRISENOX 10 MG/10 ML AMPULE 9/1/2010 99/99/9999 E0167386-0411-51 J9020 ASPARAGINASE, NOS ELSPAR 10,000 UNITS VIAL 9/1/2010 3/20/2015 E0167211-0102-01 J9025 INJECTION, AZACITIDINE, 1 MG VIDAZA 100 MG VIAL 9/1/2010 99/99/9999 E0158468-0100-01 J9027 INJECTION, CLOFARABINE, 1 MG CLOLAR 20 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100052-0602-02 J9031 BCG (INTRAVESICAL) PER INSTALLATION BCG VACCINE (TICE STRAIN) VIAL 9/1/2010 99/99/9999 E0100052-0603-02 J9031 BCG (INTRAVESICAL) PER INSTALLATION BCG VACCINE (TICE STRAIN) VIAL 9/1/2010 3/31/2011 E0163459-0391-20 J9033 INJECTION, BENDAMUSTINE HCL, 1 MG TREANDA 100 MG VIAL 9/1/2010 99/99/9999 E0150242-0060-01 J9035 INJECTION, BEVACIZUMAB(AVASTIN) AVASTIN 100 MG/4 ML VIAL 9/1/2010 99/99/9999 E0150242-0061-01 J9035 INJECTION, BEVACIZUMAB(AVASTIN) AVASTIN 400 MG/16 ML VIAL 9/1/2010 99/99/9999 E0163323-0137-20 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 9/1/2010 99/99/9999 E0100703-3154-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 9/1/2010 99/99/9999 E0100703-3155-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 9/1/2010 99/99/9999 E0100703-3155-91 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNITS VIA 9/1/2010 12/31/2010 E0155390-0005-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 9/1/2010 9/30/2011 E0155390-0006-01 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 9/1/2010 9/30/2011 E0161703-0323-22 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 30 UNIT VIAL 9/1/2010 99/99/9999 E0161703-0332-18 J9040 BLEOMYCIN SULFATE, 15 UNITS BLEOMYCIN SULFATE 15 UNIT VIAL 9/1/2010 99/99/9999 E0163020-0049-01 J9041 VELCADE VELCADE 3.5 MG VIAL 9/1/2010 99/99/9999 E0166758-0047-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0166758-0047-02 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 9/1/2010 99/99/9999 E0166758-0047-03 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 9/1/2010 99/99/9999 E0166758-0047-04 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 9/1/2010 99/99/9999 E0100703-3249-11 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 9/1/2010 99/99/9999 E0100703-4244-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100703-4246-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 9/1/2010 99/99/9999 E0100703-4248-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 9/1/2010 99/99/9999 E0150111-0965-76 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 9/1/2010 10/31/2010 E0150111-0966-76 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 9/1/2010 10/31/2010 E0155390-0150-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 9/1/2010 9/30/2011 E0155390-0151-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 9/1/2010 9/30/2011 E0155390-0152-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG VIAL 9/1/2010 9/30/2011 E0155390-0153-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 9/1/2010 9/30/2011 E0155390-0154-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 9/1/2010 9/30/2011 E0155390-0155-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 9/1/2010 9/30/2011 E0155390-0156-01 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 9/1/2010 9/30/2011 E0161703-0339-18 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0161703-0339-22 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 9/1/2010 99/99/9999 E0161703-0339-50 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 9/1/2010 99/99/9999 E0161703-0339-56 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 9/1/2010 99/99/9999 E0161703-0360-18 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0161703-0360-22 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG/15 ML VIAL 9/1/2010 99/99/9999 E0161703-0360-50 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 9/1/2010 99/99/9999 E0163323-0166-10 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 50 MG VIAL 9/1/2010 3/31/2011 E0163323-0167-21 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 150 MG VIAL 9/1/2010 99/99/9999 E0163323-0172-45 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 450 MG/45 ML VIAL 9/1/2010 99/99/9999 E0163323-0172-60 J9045 CARBOPLATIN, 50 MG CARBOPLATIN 600 MG/60 ML VIAL 9/1/2010 99/99/9999 E0100015-3012-60 J9050 CARMUSTINE, 100 MG BICNU 100 MG VIAL 9/1/2010 9/30/2015 E0166733-0948-23 J9055 CETUXIMAB(ERBITUX) ERBITUX 100 MG/50 ML VIAL 9/1/2010 99/99/9999 E0166733-0958-23 J9055 CETUXIMAB(ERBITUX) ERBITUX 200 MG/100 ML VIAL 9/1/2010 99/99/9999 E0100069-0081-01 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 100 MG/100 ML VIAL 8/29/2012 7/31/2014 E01

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Updated 11.4.14

NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

00703-5747-11 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 50 MG/50 ML VIAL 9/1/2010 99/99/9999 E0100703-5748-11 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 100 MG/100 ML VIAL 9/1/2010 99/99/9999 E0155390-0099-01 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0112-50 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0112-99 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0187-01 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0414-50 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0414-99 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0163323-0103-51 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 50 MG/50 ML VIAL 9/1/2010 99/99/9999 E0163323-0103-64 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 200 MG/200 ML VIAL 9/1/2010 99/99/9999 E0163323-0103-65 J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN 100 MG/100 ML VIAL 9/1/2010 99/99/9999 E0100703-5747-11 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 50 MG/50 ML VIAL 9/1/2010 99/99/9999 E0100703-5748-11 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 100 MG/100 ML VIAL 9/1/2010 99/99/9999 E0155390-0099-01 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0112-50 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0112-99 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0187-01 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0414-50 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0414-99 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 1 MG/ML VIAL 9/1/2010 9/30/2011 E0163323-0103-51 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 50 MG/50 ML VIAL 9/1/2010 99/99/9999 E0163323-0103-64 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 200 MG/200 ML VIAL 9/1/2010 99/99/9999 E0163323-0103-65 J9062 CISPLATIN, 50 MG VIAL CISPLATIN 100 MG/100 ML VIAL 9/1/2010 99/99/9999 E0155390-0115-01 J9065 CLADRIBINE INJECTION, PER 1 MG CLADRIBINE 10 MG/10 ML VIAL 9/1/2010 12/31/2012 E0155390-0124-01 J9065 CLADRIBINE INJECTION, PER 1 MG CLADRIBINE 10 MG/10 ML VIAL 9/1/2010 3/31/2014 E0159676-0201-01 J9065 CLADRIBINE INJECTION, PER 1 MG LEUSTATIN 10 MG/10 ML VIAL 9/1/2010 10/1/2012 E0163323-0140-10 J9065 CLADRIBINE INJECTION, PER 1 MG CLADRIBINE 10 MG/10 ML VIAL 9/1/2010 99/99/9999 E0110019-0957-11 J9092 CYCLOPHOSPHAMIDE, 2.0 GRAM CYCLOPHOSPHAMIDE 2 GM VIAL 9/1/2010 99/99/9999 E0100015-0502-41 J9095 CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG CYTOXAN 500 MG VIAL 9/1/2010 10/31/2010 E0110019-0955-01 J9095 CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG CYCLOPHOSPHAMIDE 500 MG VIAL 9/1/2010 99/99/9999 E0100015-0505-41 J9096 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM CYTOXAN 1 GM VIAL 9/1/2010 11/30/2010 E0110019-0956-01 J9096 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM CYCLOPHOSPHAMIDE 1 GM VIAL 9/1/2010 99/99/9999 E0110019-0957-01 J9097 CYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 GRAMS CYCLOPHOSPHAMIDE 2 GM VIAL 9/1/2010 99/99/9999 E0157665-0331-01 J9098 INJECTION, CYTARABINE LIPOSOME, 10 MG DEPOCYT 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0155390-0131-10 J9100 INJECTION, CYTARABINE, 100 MG CYTARABINE 100 MG VIAL 9/1/2010 4/30/2014 E0155390-0806-10 J9100 INJECTION, CYTARABINE, 100 MG CYTARABINE 100 MG VIAL 9/1/2010 7/31/2013 E0161703-0305-38 J9100 INJECTION, CYTARABINE, 100 MG CYTARABINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0155390-0132-10 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 500 MG VIAL 9/1/2010 11/30/2013 E0155390-0133-01 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 1 GM VIAL 9/1/2010 6/30/2014 E0155390-0134-01 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 2 GM VIAL 9/1/2010 9/30/2011 E0155390-0807-10 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 500 MG VIAL 9/1/2010 3/31/2013 E0155390-0808-01 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 1 GM VIAL 9/1/2010 8/31/2014 E0155390-0809-01 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 2 GM VIAL 9/1/2010 9/30/2011 E0161703-0303-46 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0161703-0304-36 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0161703-0319-22 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 2 G/20 ML VIAL 9/1/2010 99/99/9999 E0163323-0120-20 J9110 INJECTION, CYTARABINE, 500 MG CYTARABINE 2 G/20 ML VIAL 9/1/2010 99/99/9999 E0167386-0811-55 J9120 INJECTION, DACTINOMYCIN, 0.5 MG COSMEGEN 0.5 MG VIAL 9/1/2010 5/31/2015 E0163323-0127-10 J9130 DACARBAZINE, 100 MG DACARBAZINE 100 MG VIAL 9/1/2010 99/99/9999 E0100703-5075-01 J9140 DACARBAZINE, (200 MG VIAL) DACARBAZINE 200 MG VIAL 9/1/2010 99/99/9999 E0100703-5075-03 J9140 DACARBAZINE, (200 MG VIAL) DACARBAZINE 200 MG VIAL 9/1/2010 99/99/9999 E0155390-0090-10 J9140 DACARBAZINE, (200 MG VIAL) DACARBAZINE 200 MG VIAL 9/1/2010 11/30/2012 E0161703-0327-22 J9140 DACARBAZINE, (200 MG VIAL) DACARBAZINE 200 MG VIAL 9/1/2010 99/99/9999 E0163323-0128-20 J9140 DACARBAZINE, (200 MG VIAL) DACARBAZINE 200 MG VIAL 9/1/2010 99/99/9999 E0100703-5233-13 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG DAUNORUBICIN 20 MG/4 ML VIAL 9/1/2010 99/99/9999 E0155390-0108-01 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG DAUNORUBICIN 50 MG/10 ML VIAL 9/1/2010 3/31/2014 E0155390-0108-10 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG DAUNORUBICIN 20 MG/4 ML VIAL 9/1/2010 9/30/2013 E0155390-0142-10 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG DAUNORUBICIN 20 MG/4 ML VIAL 9/1/2010 10/31/2012 E0155390-0281-10 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG CERUBIDINE 20 MG VIAL 9/1/2010 9/30/2013 E0155390-0805-10 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG CERUBIDINE 20 MG VIAL 9/1/2010 4/30/2013 E0163323-0119-08 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG DAUNORUBICIN 20 MG VIAL 9/1/2010 12/31/2011 E0163323-0124-04 J9150 DAUNORUBICIN HYDROCHLORIDE, 10 MG DAUNORUBICIN 5 MG/ML VIAL 9/1/2010 3/31/2011 E0161958-0301-01 J9151 INJECTION, DAUNORUBICIN CITRATE, LIPOSOM DAUNOXOME 2 MG/ML VIAL 9/1/2010 12/31/2011 E0166758-0050-02 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/8 ML VIAL 8/15/2011 99/99/9999 E0166758-0050-03 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 160 MG/16 ML VIAL 8/15/2011 99/99/9999 E0100409-0201-02 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/2 ML VIAL 5/25/2011 99/99/9999 E0100409-0201-10 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/8 ML VIAL 5/25/2011 99/99/9999 E0100409-0201-20 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 160 MG/16 ML VIAL 3/17/2011 99/99/9999 E0100075-8003-01 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 20 MG/ML VIAL 10/11/2010 99/99/9999 E0100075-8004-04 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 80 MG/4 ML VIAL 10/11/2010 99/99/9999 E0100955-1020-01 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/ML VIAL 3/14/2011 99/99/9999 E0100955-1021-04 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/4 ML VIAL 3/14/2011 99/99/9999 E01

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Only Fee Schedule

00075-8001-20 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 20 MG/0.5 ML VIAL 9/1/2010 5/31/2012 E0116729-0120-49 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 20 MG/0.5 ML VIAL 7/11/2011 99/99/9999 E0116729-0228-50 J9171 INJECTION, DOCETAXEL, 1 MG DOCETAXEL 80 MG/2 ML VIAL 7/11/2011 99/99/9999 E0100075-8001-80 J9171 INJECTION, DOCETAXEL, 1 MG TAXOTERE 80 MG/2 ML VIAL 9/1/2010 6/30/2013 E0167871-0007-10 J9175 INJECTION, ELIOTTS' B SOLUTION, 1 ML ELLIOTTS B SOLUTION AMPULE 9/1/2010 9/30/2011 E0161703-0359-01 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 50 MG/25 ML VIAL 9/1/2010 99/99/9999 E0161703-0359-02 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 200 MG/100 ML VIAL 9/1/2010 99/99/9999 E0161703-0359-91 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 150 MG/75 ML VIAL 9/1/2010 9/30/2011 E0161703-0359-92 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 10 MG/5 ML VIAL 9/1/2010 9/30/2011 E0110518-0104-10 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 50 MG/25 ML VIAL 9/1/2010 9/30/2011 E0110518-0104-11 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 200 MG/100 ML VIAL 9/1/2010 9/30/2011 E0163323-0151-00 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 200 MG/100 ML VIAL 9/1/2010 99/99/9999 E0163323-0151-05 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 10 MG/5 ML VIAL 9/1/2010 3/31/2011 E0163323-0151-25 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 50 MG/25 ML VIAL 9/1/2010 99/99/9999 E0163323-0151-75 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 150 MG/75 ML VIAL 9/1/2010 3/31/2011 E0100009-5091-01 J9178 INJECTION, EPIRUBICIN HCI, 2 MG ELLENCE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-5093-01 J9178 INJECTION, EPIRUBICIN HCI, 2 MG ELLENCE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-3067-11 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 50 MG/25 ML VIAL 9/1/2010 99/99/9999 E0100703-3069-11 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 200 MG/100 ML VIAL 9/1/2010 99/99/9999 E0155390-0207-01 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 50 MG/25 ML VIAL 9/1/2010 9/30/2011 E0155390-0208-01 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 200 MG/100 ML VIAL 9/1/2010 9/30/2011 E0159762-5091-01 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 50 MG/25 ML VIAL 9/1/2010 2/28/2011 E0159762-5093-01 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 200 MG/100 ML VIAL 9/1/2010 10/31/2010 E0161703-0347-35 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN HCL 50 MG VIAL 9/1/2010 99/99/9999 E0161703-0359-59 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 200 MG/100 ML VIAL 9/1/2010 99/99/9999 E0161703-0359-93 J9178 INJECTION, EPIRUBICIN HCI, 2 MG EPIRUBICIN 50 MG/25 ML VIAL 9/1/2010 99/99/9999 E0100015-3404-20 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOPHOS 100 MG VIAL 9/1/2010 99/99/9999 E0100703-5653-01 J9181 INJECTION, ETOPOSIDE, 10 MG TOPOSAR 100 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100703-5656-01 J9181 INJECTION, ETOPOSIDE, 10 MG TOPOSAR 500 MG/25 ML VIAL 9/1/2010 99/99/9999 E0100703-5657-01 J9181 INJECTION, ETOPOSIDE, 10 MG TOPOSAR 1,000 MG/50 ML VIAL 9/1/2010 99/99/9999 E0155390-0291-01 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 100 MG/5 ML VIAL 9/1/2010 6/30/2013 E0155390-0292-01 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 500 MG/25 ML VIAL 9/1/2010 4/30/2013 E0155390-0293-01 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 1,000 MG/50 ML VIAL 9/1/2010 3/31/2014 E0155390-0491-01 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 100 MG/5 ML VIAL 9/1/2010 9/30/2013 E0155390-0492-01 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 500 MG/25 ML VIAL 9/1/2010 1/31/2013 E0155390-0493-01 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 1,000 MG/50 ML VIAL 9/1/2010 5/31/2013 E0163323-0104-05 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 100 MG/5 ML VIAL 9/1/2010 99/99/9999 E0163323-0104-25 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 500 MG/25 ML VIAL 9/1/2010 99/99/9999 E0163323-0104-50 J9181 INJECTION, ETOPOSIDE, 10 MG ETOPOSIDE 1,000 MG/50 ML VIAL 9/1/2010 99/99/9999 E0100703-4852-11 J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG FLUDARABINE 50 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100703-4852-81 J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG FLUDARABINE 50 MG/2 ML VIAL 9/1/2010 3/31/2011 E0100703-5854-01 J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG FLUDARABINE 50 MG VIAL 9/1/2010 99/99/9999 E0150419-0511-06 J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG FLUDARA 50 MG VIAL 9/1/2010 6/30/2013 E0163323-0196-06 J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG FLUDARABINE 50 MG VIAL 9/1/2010 99/99/9999 E0166758-0046-01 J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG FLUDARABINE 50 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100703-3015-13 J9190 INJECTION, FLUOROURACIL, 500 MG ADRUCIL 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-3018-12 J9190 INJECTION, FLUOROURACIL, 500 MG ADRUCIL 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-3019-12 J9190 INJECTION, FLUOROURACIL, 500 MG ADRUCIL 5 GRAM/100 ML VIAL 9/1/2010 99/99/9999 E0151552-0733-01 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL POWDER 9/1/2010 3/31/2011 E0151552-0733-02 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL POWDER 9/1/2010 3/31/2011 E0151552-0733-04 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL POWDER 9/1/2010 3/31/2011 E0151552-0733-05 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL POWDER 9/1/2010 3/31/2011 E0163323-0117-10 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL 500 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0117-20 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL 1,000 MG/20 ML VL 9/1/2010 99/99/9999 E0163323-0117-51 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL 2,500 MG/50 ML VL 9/1/2010 99/99/9999 E0163323-0117-61 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL 5,000 MG/100 ML 9/1/2010 99/99/9999 E0110139-0063-50 J9190 INJECTION, FLUOROURACIL, 500 MG FLUOROURACIL 2,500 MG/50 ML VL 9/1/2010 99/99/9999 E0100002-7501-01 J9201 GEMCITABINE HCL GEMZAR 200 MG VIAL 9/1/2010 99/99/9999 E0100002-7502-01 J9201 GEMCITABINE HCL GEMZAR 1 GRAM VIAL 9/1/2010 99/99/9999 E0100310-0950-36 J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG ZOLADEX 3.6 MG IMPLANT SYRN 9/1/2010 99/99/9999 E0100310-0951-30 J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG ZOLADEX 10.8 MG IMPLANT SYRN 9/1/2010 99/99/9999 E0166758-0048-01 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100703-4432-11 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100703-4434-11 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 99/99/9999 E0100703-4434-91 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 3/31/2012 E0100781-3066-72 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 6/30/2011 E0100781-3066-75 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 10/31/2011 E0110518-0103-10 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 3/31/2011 E0161703-0349-09 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 99/99/9999 E0161703-0349-16 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 99/99/9999 E0161703-0349-36 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 500 MG/25 ML VL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

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61703-0349-61 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 9/30/2011 E0161703-0349-62 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 9/30/2011 E0163323-0193-02 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0193-05 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 99/99/9999 E0100009-7529-01 J9206 INJECTION, IRINOTECAN, 20 MG CAMPTOSAR 20 MG/ML VIAL 9/1/2010 9/1/2013 E0100009-7529-02 J9206 INJECTION, IRINOTECAN, 20 MG CAMPTOSAR 20 MG/ML VIAL 9/1/2010 6/1/2013 E0100009-1111-02 J9206 INJECTION, IRINOTECAN, 20 MG CAMPTOSAR 100 MG/5 ML VIAL 8/9/2012 99/99/9999 E0100009-7529-03 J9206 INJECTION, IRINOTECAN, 20 MG CAMPTOSAR 100 MG/5 ML VIAL 11/29/2010 99/99/9999 E0110019-0934-01 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 11/30/2010 E0110019-0934-02 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 1/30/2011 E0110019-0934-79 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 1/30/2011 E0100009-7529-04 J9206 INJECTION, IRINOTECAN, 20 MG CAMPTOSAR 40 MG/2 ML VIAL 2/28/2011 99/99/9999 E0100009-7529-05 J9206 INJECTION, IRINOTECAN, 20 MG CAMPTOSAR 300 MG/15 ML VIAL 2/8/2011 99/99/9999 E0159762-7529-01 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 40 MG/2 ML VIAL 9/1/2010 2/1/2011 E0159762-7529-02 J9206 INJECTION, IRINOTECAN, 20 MG IRINOTECAN HCL 100 MG/5 ML VL 9/1/2010 1/1/2013 E0100015-1910-12 J9207 INJECTION, IXABEPILONE, 1 MG IXEMPRA 15 MG KIT 4/1/2013 99/99/9999 E0100015-1911-13 J9207 INJECTION, IXABEPILONE, 1 MG IXEMPRA 45 MG KIT 4/1/2013 99/99/9999 E0100015-0556-05 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFEX 1 GM VIAL 9/1/2010 12/31/2010 E0100015-0557-41 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFEX 3 GM VIAL 9/1/2010 10/31/2010 E0100703-3427-11 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 1 GM/20 ML VIAL 9/1/2010 99/99/9999 E0100703-3429-11 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 3 GM/ 60 ML VIAL 9/1/2010 99/99/9999 E0110019-0925-01 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 1 GM VIAL 9/1/2010 99/99/9999 E0110019-0925-82 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 1 GM VIAL 9/1/2010 99/99/9999 E0110019-0926-02 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 3 GM VIAL 9/1/2010 99/99/9999 E0110019-0926-16 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 3 GM VIAL 9/1/2010 99/99/9999 E0163323-0142-10 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0142-12 J9208 INJECTION, IFOSFAMIDE, 1 GRAM IFOSFAMIDE 1 GM VIAL 9/1/2010 99/99/9999 E0100015-3563-02 J9209 INJECTION, MESNA, 200 MG MESNEX 1 GRAM/10 ML VIAL 9/1/2010 11/30/2010 E0100015-3563-03 J9209 INJECTION, MESNA, 200 MG MESNEX 1 GRAM/10 ML VIAL 9/1/2010 11/30/2010 E0100703-4805-03 J9209 INJECTION, MESNA, 200 MG MESNA 100 MG/ML VIAL 9/1/2010 99/99/9999 E0110019-0953-01 J9209 INJECTION, MESNA, 200 MG MESNA 1 GRAM/10 ML VIAL 9/1/2010 99/99/9999 E0110019-0953-02 J9209 INJECTION, MESNA, 200 MG MESNA 1 GRAM/10 ML VIAL 9/1/2010 99/99/9999 E0155390-0045-01 J9209 INJECTION, MESNA, 200 MG MESNA 100 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0266-01 J9209 INJECTION, MESNA, 200 MG MESNA 100 MG/ML VIAL 9/1/2010 7/31/2012 E0163323-0733-10 J9209 INJECTION, MESNA, 200 MG MESNA 100 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0733-11 J9209 INJECTION, MESNA, 200 MG MESNA 100 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0733-12 J9209 INJECTION, MESNA, 200 MG MESNA 100 MG/ML VIAL 9/1/2010 12/31/2010 E0100013-2576-91 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDAMYCIN PFS 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100013-2586-91 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDAMYCIN PFS 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100013-2596-91 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDAMYCIN PFS 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-4154-11 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN HCL 5 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100703-4155-11 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN HCL 10 MG/10 ML VL 9/1/2010 99/99/9999 E0100703-4156-11 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN HCL 20 MG/20 ML VL 9/1/2010 99/99/9999 E0155390-0215-01 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN HCL 5 MG/5 ML VIAL 9/1/2010 9/30/2011 E0155390-0216-01 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN HCL 10 MG/10 ML VL 9/1/2010 9/30/2011 E0155390-0217-01 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN HCL 20 MG/20 ML VL 9/1/2010 9/30/2011 E0159762-2576-01 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN PFS 5 MG/5 ML VIAL 9/1/2010 4/30/2012 E0159762-2586-01 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN PFS 10 MG/10 ML VL 9/1/2010 6/30/2012 E0159762-2596-01 J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 M IDARUBICIN PFS 20 MG/20 ML VL 9/1/2010 9/30/2011 E0100085-0539-01 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 50 MILLION UNITS VIAL 9/1/2010 99/99/9999 E0100085-0571-02 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 10 MILLION UNITS VIAL 9/1/2010 99/99/9999 E0100085-1110-01 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 18 MILLION UNITS VIAL 9/1/2010 99/99/9999 E0100085-1133-01 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 10 MILLION UNIT/ML 9/1/2010 99/99/9999 E0100085-1168-01 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 6 MILLION UNIT/ML VL 9/1/2010 99/99/9999 E0100085-1235-01 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 5 MILLION UNIT/ML PEN 9/1/2010 9/12/2012 E0100085-1242-01 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 3 MILLION UNIT/ML PEN 9/1/2010 9/12/2012 E0100085-1254-01 J9214 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILL INTRON A 10 MILLION UNIT PEN 9/1/2010 9/12/2012 E0154746-0001-01 J9215 INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DE ALFERON N 5 MILLION UNITS VIAL 9/1/2010 99/99/9999 E0164116-0011-01 J9216 INTERFERON, GAMMA 1-B, 3 MILLION UNITS ACTIMMUNE 100 MCG/0.5 ML VIAL 9/1/2010 4/30/2016 E0164116-0011-12 J9216 INTERFERON, GAMMA 1-B, 3 MILLION UNITS ACTIMMUNE 100 MCG/0.5 ML VIAL 9/1/2010 4/30/2016 E0100074-3473-03 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 45 MG 6MO KIT 8/30/2011 99/99/9999 E0100024-0222-05 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 22.5 MG SYRINGE KIT 9/1/2010 99/99/9999 E0100024-0605-45 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 45 MG SYRINGE KIT 9/1/2010 99/99/9999 E0100024-0610-30 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 30 MG SYRINGE KIT 9/1/2010 99/99/9999 E0100024-0793-75 J9217 LEUPROLIDE ACETATE, PER 7.5 MG ELIGARD 7.5 MG SYRINGE KIT 9/1/2010 99/99/9999 E0100074-3683-03 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-4 MONTH KIT 9/1/2010 99/99/9999 E0100300-2108-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 7.5 MG KIT 9/1/2010 12/31/2010 E0100300-2282-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 11.25 MG KIT 9/1/2010 8/1/2011 E0100300-2440-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-PED 15 MG KIT 9/1/2010 11/1/2010 E0100300-3346-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 22.5 MG 3MO KIT 9/1/2010 7/1/2011 E0100300-3642-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 7.5 MG KIT 9/1/2010 8/1/2011 E01

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Only Fee Schedule

00300-3663-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 11.25 MG 3MO KIT 9/1/2010 9/30/2011 E0100300-3683-01 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT-4 MONTH KIT 9/1/2010 7/1/2011 E0100074-3346-03 J9217 LEUPROLIDE ACETATE, PER 7.5 MG LUPRON DEPOT 22.5 MG 3MO KIT 9/1/2010 99/99/9999 E0100185-7400-85 J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KT 9/1/2010 12/31/2012 E0100703-4014-18 J9218 LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE 2WK 1 MG/0.2 ML KIT 9/1/2010 99/99/9999 E0100074-3663-03 J9218 LEUPROLIDE ACETATE, PER 1 MG LUPRON DEPOT 11.25 MG 3MO KIT 5/25/2011 99/99/9999 E0167979-0002-01 J9225 VANTAS IMPLANT SUPPRELIN LA 50 MG KIT 9/1/2010 99/99/9999 E0167979-0500-01 J9225 VANTAS IMPLANT VANTAS 50 MG KIT 9/1/2010 99/99/9999 E0167979-0002-01 J9226 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG SUPPRELIN LA 50 MG KIT 9/1/2010 99/99/9999 E0167979-0500-01 J9226 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG VANTAS 50 MG KIT 9/1/2010 99/99/9999 E0167386-0911-51 J9230 MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARGEN 10 MG VIAL 9/1/2010 7/31/2014 E0155390-0031-10 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 50 MG/2 ML VIAL 9/1/2010 3/31/2014 E0155390-0032-10 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 100 MG/4 ML VIAL 9/1/2010 3/31/2014 E0155390-0033-10 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 200 MG/8 ML VIAL 9/1/2010 3/31/2014 E0155390-0034-10 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 250 MG/10 ML VIAL 9/1/2010 3/31/2014 E0161703-0350-38 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0161703-0408-41 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 1 GRAM/40 ML VIAL 9/1/2010 99/99/9999 E0163323-0121-02 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0121-04 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0121-08 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0121-10 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0121-40 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0123-02 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0123-10 J9250 METHOTREXATE SODIUM MIX, 2 CC OR 5 MG METHOTREXATE 25 MG/ML VIAL 9/1/2010 99/99/9999 E0155390-0143-01 J9260 METHOTREXATE SODIUM, 50 MG METHOTREXATE 1 GM VIAL 9/1/2010 5/31/2013 E0163323-0122-50 J9260 METHOTREXATE SODIUM, 50 MG METHOTREXATE 1 GM VIAL 9/1/2010 99/99/9999 E0100007-4401-06 J9261 INJECTION, NELARABINE, 50 MG ARRANON 250 MG VIAL 9/1/2010 99/99/9999 E0100024-0590-10 J9263 ELOXATIN ELOXATIN 50 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100024-0591-20 J9263 ELOXATIN ELOXATIN 100 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100024-0592-40 J9263 ELOXATIN ELOXATIN 200 MG/40 ML VIAL 9/1/2010 8/31/2013 E0168817-0134-50 J9264 INJECTION, PACLITAXEL ABRAXANE 100 MG VIAL 9/1/2010 99/99/9999 E0100703-4766-01 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/1/2010 99/99/9999 E0100703-4767-01 J9265 PACLITAXEL 30 MG PACLITAXEL 150 MG/25 ML VIAL 9/1/2010 99/99/9999 E0166758-0043-01 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 9/1/2010 99/99/9999 E0166758-0043-02 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/1/2010 99/99/9999 E0166758-0043-03 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/1/2010 99/99/9999 E0155390-0114-05 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 9/1/2010 3/31/2014 E0155390-0114-20 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/1/2010 4/30/2013 E0155390-0114-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/1/2010 7/31/2013 E0155390-0304-05 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 9/1/2010 11/30/2012 E0155390-0304-20 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/1/2010 4/30/2013 E0155390-0304-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/1/2010 4/30/2013 E0155390-0314-05 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 9/1/2010 3/31/2012 E0155390-0314-20 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/1/2010 6/30/2012 E0155390-0314-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/1/2010 12/31/2012 E0161703-0342-09 J9265 PACLITAXEL 30 MG PACLITAXEL 30 MG/5 ML VIAL 9/1/2010 99/99/9999 E0161703-0342-22 J9265 PACLITAXEL 30 MG PACLITAXEL 100 MG/16.7 ML VIAL 9/1/2010 99/99/9999 E0161703-0342-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/1/2010 99/99/9999 E0168817-0134-50 J9265 PACLITAXEL 30 MG ABRAXANE 100 MG VIAL 9/1/2010 99/99/9999 E0163323-0763-50 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/1/2010 99/99/9999 E0100703-4768-01 J9265 PACLITAXEL 30 MG PACLITAXEL 300 MG/50 ML VIAL 9/1/2010 99/99/9999 E0157665-0002-02 J9266 PEGASPARGASE ONCASPAR 750 UNIT/ML VIAL 9/1/2010 12/6/2011 E0100409-0801-01 J9268 PENTOSTATIN NIPENT 10 MG VIAL 9/1/2010 99/99/9999 E0155390-0244-01 J9268 PENTOSTATIN PENTOSTATIN 10 MG VIAL 9/1/2010 3/31/2014 E0155390-0251-01 J9280 MITOMYCIN INJECTION MITOMYCIN 5 MG VIAL 9/1/2010 1/31/2013 E0155390-0451-01 J9280 MITOMYCIN INJECTION MITOMYCIN 5 MG VIAL 9/1/2010 11/30/2012 E0155390-0252-01 J9290 MITOMYCIN, 20 MG MITOMYCIN 20 MG VIAL 9/1/2010 1/31/2013 E0155390-0452-01 J9290 MITOMYCIN, 20 MG MITOMYCIN 20 MG VIAL 9/1/2010 1/31/2013 E0155390-0253-01 J9291 MITOMYCIN, 40 MG MITOMYCIN 40 MG VIAL 9/1/2010 3/31/2014 E0155390-0453-01 J9291 MITOMYCIN, 40 MG MITOMYCIN 40 MG VIAL 9/1/2010 10/31/2012 E0100703-4680-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 9/1/2010 99/99/9999 E0100703-4685-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100703-4686-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 9/1/2010 99/99/9999 E0144087-1520-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG NOVANTRONE 2 MG/ML VIAL 9/1/2010 11/30/2013 E0155390-0083-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 9/1/2010 9/30/2011 E0155390-0084-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 9/1/2010 9/30/2011 E0155390-0085-01 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 9/1/2010 9/30/2011 E0161703-0343-18 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 9/1/2010 99/99/9999 E0161703-0343-65 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 9/1/2010 99/99/9999 E0161703-0343-66 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 9/1/2010 99/99/9999 E0163323-0132-10 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 20 MG/10 ML VIAL 9/1/2010 99/99/9999 E01

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NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

Only Fee Schedule

63323-0132-12 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 25 MG/12.5 ML VL 9/1/2010 99/99/9999 E0163323-0132-15 J9293 MITOXANTRONE HYDROCHLORIDE, 5 MG MITOXANTRONE 30 MG/15 ML VIAL 9/1/2010 99/99/9999 E0100008-4510-01 J9300 GEMTUZUMB OZOGAMICIN MYLOTARG 5 MG VIAL 9/1/2010 12/31/2010 E0155513-0954-01 J9303 INJECTION, PANITUMUMAB, 10 MG VECTIBIX 100 MG/5 ML VIAL 9/1/2010 99/99/9999 E0155513-0956-01 J9303 INJECTION, PANITUMUMAB, 10 MG VECTIBIX 400 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100002-7623-01 J9305 INJECTION, PEMETREXED, 10 MG ALIMTA 500 MG VIAL 9/1/2010 99/99/9999 E0150242-0051-21 J9310 INJECTION, RITUXIMAB, 100 MG RITUXAN 10 MG/ML VIAL 9/1/2010 99/99/9999 E0150242-0053-06 J9310 INJECTION, RITUXIMAB, 100 MG RITUXAN 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-4636-01 J9320 INJECTION, STREPTOZOCIN, 1 GRAM ZANOSAR 1 GM POWDER VIAL 9/1/2010 99/99/9999 E0100008-1179-01 J9330 INJECTION, TEMSIROLIMUS, 1 MG TORISEL 25 MG KIT 9/1/2010 99/99/9999 E0155390-0030-10 J9340 INJECTION, THIOTEPA, 15 MG THIOTEPA 15 MG VIAL 9/1/2010 3/31/2014 E0100703-4402-11 J9340 INJECTION, THIOTEPA, 15 MG VINCASAR PFS 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100007-4201-01 J9350 INJECTION, TOPOTECAN, 4 MG HYCAMTIN 4 MG VIAL 9/1/2010 99/99/9999 E0100007-4201-05 J9350 INJECTION, TOPOTECAN, 4 MG HYCAMTIN 4 MG VIAL 9/1/2010 9/30/2012 E0150242-0134-68 J9355 INJECTION, TRASTUZUMAB, 10 MG HERCEPTIN 440 MG VIAL 9/1/2010 99/99/9999 E0155390-0091-10 J9360 INJECTION, VINBLASTINE SULFATE, 1 MG VINBLASTINE SULF 10 MG VIAL 9/1/2010 4/30/2013 E0163323-0278-10 J9360 INJECTION, VINBLASTINE SULFATE, 1 MG VINBLASTINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-4402-11 J9370 VINCRISTINE SULFATE, 1 MG VINCASAR PFS 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-4412-11 J9370 VINCRISTINE SULFATE, 1 MG VINCASAR PFS 2 MG/2 ML VIAL 9/1/2010 99/99/9999 E0161703-0309-06 J9370 VINCRISTINE SULFATE, 1 MG VINCRISTINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0161703-0309-16 J9370 VINCRISTINE SULFATE, 1 MG VINCRISTINE 2 MG/2 ML VIAL 9/1/2010 99/99/9999 E0164370-0210-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 6/1/2014 E0164370-0250-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 6/1/2014 E0166758-0045-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0166758-0045-02 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100703-4182-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-4182-81 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 3/31/2011 E0100703-4182-91 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 5/31/2012 E0100703-4183-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100703-4183-81 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 3/31/2011 E0100703-4183-91 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 12/31/2012 E0155390-0069-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0070-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 3/31/2014 E0155390-0267-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 12/31/2011 E0161703-0341-06 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0161703-0341-09 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0163323-0148-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0148-05 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0155390-0268-01 J9390 INJECTION, VINORELBINE TARTRATE, 10 MG VINORELBINE 50 MG/5 ML VIAL 9/1/2010 12/31/2011 E0100310-0720-25 J9395 INJECTION, FULVESTRANT, 25 MG FASLODEX 125 MG/2.5 ML SYRNGE 9/1/2010 12/31/2010 E0100310-0720-50 J9395 INJECTION, FULVESTRANT, 25 MG FASLODEX 250 MG/5 ML SYRINGE 9/1/2010 99/99/9999 E0158914-0155-75 J9600 INJECTION, PORFIMER SODIUM, 75 MG PHOTOFRIN 75 MG VIAL 9/1/2010 3/31/2011 E0100015-1910-12 J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC IXEMPRA 15 MG KIT 9/1/2010 3/31/2013 E0100015-1911-13 J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC IXEMPRA 45 MG KIT 9/1/2010 3/31/2013 E01