Specialty Pharmacy Benefit HCPCS Code/Drug List

LDI Specialty Carve-Out Program If you have questions, please feel free to contact us at 314-652-2121, option 5, or 866-516-2121 or e-mail us at SpecialtyCarveOut@LDIRx.com.

HCPCS Code

Brand Drug Name Generic Drug Name

C9003 Synagis palivizumab C9232 Elaprase idursulfase C9236 Soliris eculizumab J0129 Orencia abatacept J0135 Humira adalimumab J0180 Fabrazyme agalsidase beta J0200 Trovan alatrofloxacin mesylate J0207 Ethyol amifostine J0270 Caverject alprostadil J0290 Omnipen-N ampicillin sodium J0295 Unasyn ampicillin sodium/ sulbactam J0456 Zithromax azithromycin J0530, J0540, J0550

Bicillin C-R penicillin G benzathine & penicillin G procaine

J0560, J0570, J0580

Bicillin L-A penicillin G benzathine

J0585 Botox botulinum toxin type A J0630 Calcimar calcitonin-salmon J0637 Cancidas caspofungin acetate J0640 Wellcovorin leucovorin calcium J0690 Ancef cefazolin sodium J0692 Maxipime cefepime HCL J0694 Mefoxin cefoxitin sodium J0696 Rocephin ceftriaxone sodium J0697 Kefurox cefuroxime sodium J0698 Claforan cefotaxime sodium J0710 Cefadyl cephapirin sodium J0713 Fortaz ceftazidime J0715 Cefizox ceftizoxime sodium J0725 Novarel chorionic gonadotropin J0725 Pregnyl chorionic gonadotropin (hCG) for inj J0725 Profasi chorionic gonadotropin (hCG) for inj J0743 Primaxin cilastatin sodium imipenum J0744 Cipro ciprofloxacin J0878 Cubicin daptomycin J0881 J0882

Aranesp darbepoetin alfa

Specialty Pharmacy Benefit HCPCS Code/Drug List

HCPCS Code

Brand Drug Name Generic Drug Name

J0885 J0886

Epogen, Procrit epoetin alfa

J0894 Dacogen decitabine J1000 Depo-estradiol estradiol cypionate in oil J1051, J1055

Depo-Provera medroxyprogesterone ac

J1056 Lunelle medroxyprogesterone ac/ estradiol cypionate J1060, J1070, J1080

Depo-testosterone testosterone cypionate in oil

J1110 D.H.E. 45 dihydroergotamine mesylate J1190 Zinecard dexrazoxane hcl J1260 Anzemet dolasetron mesylate J1335 Invanz ertapenem sodium J1436 Didronel etidronate disodium J1438 Enbrel etanercept J1440, J1441

Neupogen filgastrim

J1450 Diflucan fluconazole J1460, J1470, J1480, J1490, J1500, J1510, J1520, J1530, J1540, J1550, J1560, J1561

Gammar, Baygam, Gamastan,

gamma globulin

J1562 Vivaglobin immune globulin IV (IVIG) J1565 Respigam respiritory syncitial virus immune globulin intravenous J1566 immune globulin immune globulin IV (IVIG) J1567 immune globulin immune globulin IV (IVIG) J1580 Gentamicin Sulfate gentamicin sulfate J1595 Copaxone glatiramer acetate J1620 Factrel gonadorelin HCL J1626 Kytril granisertron HCL J1645 Fragmin dalteparin J1650 Lovenox enoxaparin J1652 Arixtra fondaparinux J1655 Innohep tinzaparin J1740 Boniva ibandronate sodium J1745 Remicade infliximab J1756 Venofer iron sucrose J1785 Cerezyme imiglucerase

Specialty Pharmacy Benefit HCPCS Code/Drug List

HCPCS Code

Brand Drug Name Generic Drug Name

J1825 Rebif interferon beta-1a J1825 Avonex interferon beta-1a J1830 Betaseron

Actimmune interferon beta-1b

J1950 Lupron Depot leuprolide acetate J1956 Levaquin levofloxacin J2185 Merrem meropenem J2280 Avelox moxifloxacin J2353, J2354

Sandostatin octreotide acetate

J2355 Neumega opreleukin (interleukin II; IL-II) J2405 Zofran ondasentron HCL J2430 Aredia pamidronate J2469 Aloxi palonosetron HCL J2501 Zemplar paricalcitol J2505 Neulasta pegfilgrastim J2510 Pfizerpen A.S. penicillin G procaine, aqueous J2540 Pfizerpen penicillin G potassium J2543 Zosyn piperacillin sodium/tazobactam sodium J2597 DDAVP desmopressin acetate J2700 Bactocill oxacillin sodium J2788, J2790

Rhogam rho(D) immune globulin (Rho[D] IGIM)

J2792 Winrho SDF rho(D) immune globulin (Rho[D] IGIM) J2820 Leukine sargramostim (granulocyte macrophage colony stimulatging factor; GM-CSF)

J2940 Protropin somatrem J2941 Genotropin somatotropin J2941 Humatrope somatotropin J2941 Nutropin somatotropin J2941 Nutropin Depot somatotropin long acting J2941 Serostim somatropin J3110 Forteo teriparatide J3130 Delatestryl testosterone enanthate J3240 Thyrogen thyrotropin alpha J3260 Nebcin tobramycin sulfate J3315 Trelstar Depot triptorelin pamoate J3370 Vancocin vancomycin HCL J3487 Zometa zoledronic acid J3490 Unclassified Drugs Unclassified Drugs *Need the product NDC to Re-Price J7190 Hemofil M antihemophilic factor (factor VIII; AHF) J7190 Kogenate FS antihemophilic factor (factor VIII; AHF) J7190 Monarc-M antihemophilic factor (factor VIII; AHF) J7190 Monoclate-P antihemophilic factor (factor VIII; AHF) J7191 Autoplex-T anti-inhibitor coagulant complex J7191 Hyate-C (porcine) antihemophilic factor (factor VIII; AHF) J7192 Helixate FS antihemophilic factor (factor VIII; AHF)

Specialty Pharmacy Benefit HCPCS Code/Drug List

HCPCS Code

Brand Drug Name Generic Drug Name

J7192 Recombinate antihemophilic factor (factor VIII; AHF) J7193 AlphaNine SD factor IX concentrates J7193 Mononine factor IX concentrates J7194 Proplex-T factors II, VII, IX, and X concentrates J7195 BeneFix factor IX concentrates J7195 Konyne 80 factor IX concentrates J7198 Feiba VH anti-inhibitor coagulant complex J7317 Hyalgan sodium hyaluronate (inactive after 12/31/06) J7319 Synvisc, Hyalgan sodium hyaluronate J7320 Synvisc sodium hyaluronate/ hylan GF-20 (inactive after 12/31/06) J7504 Atgam lymphocyte immune globulin, antithymocyte globulin J7513 Zenapax daclizumab J7682 Tobi tobramycin J8520 J8521

Xeloda capcitabine

J8565 Iressa gefitinib J8600 Alkeran melphalan J8700 Temodar temozolomide J9000 Adriamycin PFS doxorubicin HCL J9001 Doxil doxorubicin HCL J9010 Campath alemtuzumab J9015 Proleukin aldesleukin (interleukin-2; IL-2) J9017 Trisenox arsenic trioxide J9020 Elspar asparaginase J9025 Vidaza azacitidine J9035 Avastin becacizumab J9040 Blenoxane bleomycin sulfate J9041 Velcade bortezomib J9045 Paraplatin carboplatin J9050 BiCNU carmustine J9055 Erbitux cetuximab J9060, J9062

Platinol AQ cisplatin

J9065 Leustatin cladribine J9070, J9080, J9090, J9091, J9092

Cytoxan cyclophosphamide

J9093, J9094, J9095, J9096, J9097

Cytoxan, lyophilized cyclophosphamide

J9098 Depocyt cytarabine liposome J9100, J9110

Cytosar-U cytarabine

Specialty Pharmacy Benefit HCPCS Code/Drug List

HCPCS Code

Brand Drug Name Generic Drug Name

J9120 Cosmegen dactinomycin J9130, J9140

DTIC-Dome dacarbazine

J9150 Cerubidine daunorubicin HCL J9151 Daunoxome daunorubicin citrate, liposomal J9160 Ontak denileukin diftitox J9170 Taxotere docetaxel J9178 Ellence epirubicin HCL J9181, J9182

VePesid etoposide

J9185 Fludara fludarabine phosphate J9190 Adrucil fluorouracil J9200 FUDR floxuridine J9201 Gemzar gemcitabine HCL J9202 Zoladex goserelin acetate J9206 Camptosar irinotecan J9208 Ifex ifosfamide J9209 Mesnex mesna J9211 Idamycin idarubicin HCL J9212 Infergen interferon-alfacon-1 J9213 Roferon-A interferon alfa-2a J9214 Intron-A intereron alfa-2b J9215 Alferon N interferon alfa-N3 human leukocyte derived J9216 Actimmune interferon gamma-1b J9217, J9218, J9219

Lupron leuprolide acetate

J9245 Alkeran melphalan HCL J9250, J9260

Folex methotrexate sodium

J9261 Arranon nelarabine J9263 Eloxatin oxaliplatin J9265 Taxol paclitaxel J9266 Oncaspar peaspargase J9268 Nipent pentostatin J9270 Mithacin plicamycin J9280, J9290, J9291

Mitomycin mitomycin

J9293 Novantrone mitoxantrone HCL J9300 Mylotarg gemtuzumab ozogamicin J9305 Alimta pemetrexed J9310 Rituxan rituximab J9320 Zanosar streptozocin J9350 Topotecan hycamtin J9355 Herceptin trastuzumab J9357 Valstar valrubicin

Specialty Pharmacy Benefit HCPCS Code/Drug List

HCPCS Code

Brand Drug Name Generic Drug Name

J9360 Velban vinblastine sulfate J9370, J9375, J9380

Oncovin vincristine sulfate

J9390 Navelbine vinorelbine tartrate Q3025, Q3026

Avonex interferon beta 1-a (also see J1825)

Q4081 Epogen, Procrit epoetin alfa Q4083 Hyalgan, Supartz sodium hyaluronate Q4084 Synvisc sodium hyaluronate Q4085 Euflexxa sodium hyaluronate Q4086 Orthovisc sodium hyaluronate Q4092 Gamunex immune globulin IV (IVIG) S0145 Pegasys pegylated interferon alpha-2a S0146 Pegasys pegylated interferon alpha-2b S0162 Raptiva efalizumab