| Actemra |
Tocilizumab |
J3262 |
Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) |
MP-RX-FP-59-23 |
| Advate |
Antihemophilic Factor (Rcmb) Plasma/Albumin Free (rAHF-PFM) |
J7192 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Adynovate |
Antihemophilic Factor (Recombinant) Pegylated |
J7207 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Afstyla |
Antihemophilic Factor (Recombinant) Single Chain |
J7210 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Aimovig |
Erenumab |
C9399; J3490; J3590 |
CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) |
MP-RX-FP-17-23 |
| Ajovy |
Fremanezumab-vfrm |
J3031 |
CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) |
MP-RX-FP-17-23 |
| Akynzeo |
Netupitant, palonosetron |
J8655 |
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) |
LCD: L33827 - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) |
| Tyvaso |
Treprostinil |
J7686 |
Nebulizers |
LCD - Nebulizers (L33370) |
| Alphanate |
Antihemophilic viii/vwf comp |
J7186 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| AlphaNine |
Coagulation Factor IX |
J7193 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Alprolix |
Coagulation Factor IX (Recomb) Fc Fusion Protein (rFIXFc) |
J7201 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Altuviio |
Factor VIII/von Willebrand factor complex, recombinant |
J7214 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Anktiva |
Nogapendekin alfa inbakicept-pmln |
J9999 |
Anktiva_PartB_MedPol_2024 |
MP-RX-FP-154-24 |
| Aralast |
Alpha1-Proteinase Inhibitor (Human) |
J0256 |
Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] |
MP-RX-FP-06-23 |
| Aranesp (Albumin Free) |
Darbepoetin alfa, non-esrd |
J0881 |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Aranesp (Albumin Free) |
Darbepoetin alfa, esrd use |
J0882 |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Atgam |
Lymphocyte Immune Globulin,Anti-Thymocyte Globulin (Equine) |
J7504 |
Antithymocyte Globulin Equine, (Atgam) |
MP-RX-FP-08-24 |
| Avastin |
Bevacizumab |
J9035 |
Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) |
MP-RX-FP-13-23 |
| Avsola |
Infliximab-axxq |
Q5121 |
Tumor Necrosis Factor Antagonists |
MP-RX-FP-96-23 |
| BeneFix |
Coagulation Factor IX (Recombinant) |
J7195 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Benlysta |
Belimumab |
J0490 |
Benlysta (belimumab) |
MP-RX-FP-11-23 |
| Berinert |
C1 Esterase Inhibitor (Human) |
J0597 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| Bonsity |
Teriparatide |
J3110 |
Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) |
MP-RX-FP-37-23 |
| Botox |
OnabotulinumtoxinA |
J0585 |
Botulinum Toxins |
LCD: L33274 - Botulinum Toxins |
| Cabenuva |
Cabotegravir & Rilpivirine |
J0741 |
Cabotegravir extended-release; rilpivirine extended-release (Cabenuva) |
MP-RX-FP-16-23 |
| Cerezyme |
Imiglucerase |
J1786 |
Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) |
MP-RX-FP-29-23 |
| Cinqair |
Reslizumab |
J2786 |
Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] |
MP-RX-FP-58-23 |
| Cinryze |
C1 Esterase Inhibitor (Human) |
J0598 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| Coagadex |
Coagulation Factor X (Human) |
J7175 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Corifact |
Factor XIII Concentrate (Human) |
J7180 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Tretten |
Coagulation Factor XIII A-Subunit (Recombinant) |
J7181 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Darzalex |
Daratumumab |
J9145 |
Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) |
MP-RX-FP-21-23 |
| Darzalex Faspro |
Daratumumab and hyaluronidase-fijh |
J9144 |
Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) |
MP-RX-FP-21-23 |
| Dodex |
Cyanocobalamin |
J3420 |
Vitamin B12 Injections |
LCD - Vitamin B12 Injections (L33967) (cms.gov) |
| Duopa |
Carbidopa-Levodopa |
J7340 |
Carbidopa and levodopa enteral suspension (Duopa) |
MP-RX-FP-22-23 |
| Dupixent |
Dupilumab |
C9399; J3490; J3590 |
Dupilumab (Dupixent) |
MP-RX-FP-23-23 |
| Durolane |
Sodium Hyaluronate (Viscosupplement) |
J7318 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Supartz |
Hyaluronan |
J7321 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Visco-3 |
Hyaluronan |
J7321 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Durysta |
Bimatoprost |
J7351 |
Durysta [Bimatoprost Implant] |
MP-RX-FP-24-23 |
| Dysport |
AbobotulinumtoxinA |
J0586 |
Botulinum Toxins |
LCD: L33274 - Botulinum Toxins |
| Egrifta |
Tesamorelin Acetate |
J3490; J3590 |
Tesamorelin (Egrifta) |
MP-RX-FP-25-23 |
| Elelyso |
Taliglucerase Alfa |
J3060 |
Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) |
MP-RX-FP-29-23 |
| Eloctate |
Antihemophilic Factor (Recombinant) Fc Fusion Protein(BDD-rFVIIIFc) |
J7205 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Emend |
Aprepitant, oral |
J8501 |
Oral antiemetic drugs: Aprepitant |
MP-RX-FP-07-23 |
| Emgality |
Galcanezumab |
C9399; J3490; J3590 |
CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) |
MP-RX-FP-17-23 |
| Enhertu |
fam-trastuzumab deruxtecan-nxk |
J9358 |
Trastuzumab – Trastuzumab Biologics |
MP-RX-FP-161-24 |
| Entyvio |
Vedolizumab |
J3380 |
Vedolizumab (Entyvio) |
MP-RX-FP-28-23 |
| Epogen |
Epoetin alfa, esrd |
Q4081 |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Epogen |
Epoetin alfa, non-esrd |
J0885 |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Esperoct |
Antihemophilic Factor (Recombinant) Glycopegylated-exei |
J7204 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Euflexxa |
Sodium Hyaluronate (Viscosupplement) |
J7323 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Evenity |
Romosozumab-aqqg |
J3111 |
Romosozumab (Evenity) |
MP-RX-FP-32-23 |
| Fasenra |
Benralizumab |
J0517 |
Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] |
MP-RX-FP-58-23 |
| Fasenra Pen |
Benralizumab |
J0517 |
Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] |
MP-RX-FP-58-23 |
| Feiba NF |
Antiinhibitor Coagulant Complex |
J7198 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Feraheme |
Ferumoxytol |
Q0138 |
Iron Agents |
MP-RX-FP-44-23 |
| Ferrlecit |
Sodium ferric gluconate/sucrose complex |
J2916 |
Iron Agents |
MP-RX-FP-44-23 |
| Fibryga |
Fibrinogen Concentrate (Human) |
J7177 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Firazyr |
Icatibant Acetate |
J1744 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| Forteo |
Teriparatide (Recombinant) |
J3110 |
Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) |
MP-RX-FP-37-23 |
| Fulphila |
Pegfilgrastim-jmdb |
Q5108 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Gammagard |
Gammagard liquid injection |
J1569 |
Immunoglobulins |
MP-RX-FP-40-23 |
| Gammagard S/D |
Immune Globulin (Human) IV |
J1566 |
Immunoglobulins |
MP-RX-FP-40-23 |
| Gamunex |
Immune Globulin (Human) IV |
J1561 |
Immunoglobulins |
MP-RX-FP-40-23 |
| Gazyva |
Obinutuzumab |
J9301 |
Obinutuzumab (Gazyva®) |
MP-RX-FP-33-23 |
| Gel-One |
Cross-Linked Hyaluronate |
J7326 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Gel-Syn |
Hyaluronan or derivative, for intra-articular injection |
J7328 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| GenVisc 850 |
Sodium Hyaluronate (Viscosupplement) |
J7320 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Glassia |
Alpha1-Proteinase Inhibitor (Human) |
J0257 |
Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] |
MP-RX-FP-06-23 |
| Granix |
Tbo-Filgrastim |
J1447 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Haegarda |
C1 Esterase Inhibitor (Human) |
J0599 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| Hemlibra |
Emicizumab-kxwh |
J7170 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Hemofil-M |
Antihemophilic Factor (Human) |
J7190 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Herceptin |
Trastuzumab |
J9355 |
Trastuzumab – Trastuzumab Biologics |
MP-RX-FP-161-24 |
| Herceptin Hylecta |
Trastuzumab, and hyaluronidase-oysk |
J9356 |
Trastuzumab – Trastuzumab Biologics |
MP-RX-FP-161-24 |
| Humalog®, Humulin®, Novolin®, Novolog®, Insulin Lispro®, Apidra Solostar® |
Insulin Lispro or Aspart for insulin pump use |
J1817, S5550, S5551 |
Infusion Pumps |
NCD: 280.14 - Infusion Pumps |
| Humate-P |
Antihemophilic Factor/von Willebrand Factor Complex (Human) |
J7187 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Hyalgan |
Sodium Hyaluronate (Viscosupplement) |
J7321 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Hymovis |
Hyaluronan |
J7322 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Hyqvia |
Immune Globulin (Human)-Hyaluronidase (Human Recombinant) |
J1575 |
Immunoglobulins |
MP-RX-FP-40-23 |
| Idelvion |
Coagulation Factor IX Recomb Albumin Fusion Protein (rIX-FP) |
J7202 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Ilumya |
Tildrakizumab-asmn |
J3245 |
Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] |
MP-RX-FP-61-23 |
| Iluvien |
Fluocinolone acetonide intravitreal implant |
J7313 |
Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] |
MP-RX-FP-43-23 |
| Infed |
Iron dextran |
J1750 |
Iron Agents |
MP-RX-FP-44-23 |
| Inflectra |
Infliximab-dyyb |
Q5103 |
Tumor Necrosis Factor Antagonists |
MP-RX-FP-96-23 |
| Injectafer |
Ferric carboxymaltose |
J1439 |
Iron Agents |
MP-RX-FP-44-23 |
| ISTODAX |
Romidepsin |
J9319 |
Romidepsin (Istodax®) |
MP-RX-FP-45-23 |
| Inflectra |
Infliximab-dyyb |
Q5103 |
Tumor Necrosis Factor Antagonists |
MP-RX-FP-96-23 |
| Ixifi |
Infliximab-qbtx |
Q5109 |
Tumor Necrosis Factor Antagonists |
MP-RX-FP-96-23 |
| Ixinity |
Coagulation Factor IX (Recombinant) |
J7195 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Jivi |
Antihemophilic Factor (Recombinant) PEGylated-aucl (BDD-rFVIII PEG-aucl) |
J7208 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Kalbitor |
Ecallantide |
J1290 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| Kevzara |
Sarilumab |
C9399; J3490; J3590 |
Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) |
MP-RX-FP-59-23 |
| Keytruda |
Pembrolizumab |
J9271 |
Pembrolizumab (Keytruda®) |
MP-RX-FP-49-23 |
| Koate |
Antihemophilic Factor (Human) |
J7190 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Koate-DVI |
Antihemophilic Factor (Human) |
J7190 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Kogenate FS |
Antihemophilic Factor (Recombinant) (rFVIII) |
J7192 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Kovaltry |
Antihemophilic Factor (Recombinant) Plasma/Albumin Free (rAHF-PFM) |
J7211 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Krystexxa |
Pegloticase |
J2507 |
Krystexxa (pegloticase) |
MP-RX-FP-50-23 |
| Lanreotide |
Lanreotide (cipla) |
J1932 |
Lanreotide (Somatuline Depot) |
MP-RX-FP-83-23 |
| Lemtrada |
Alemtuzumab |
J0202 |
Alemtuzumab [Lemtrada] |
MP-RX-FP-52-23 |
| Leqvio |
Inclisiran, 1 mg |
J1306 |
Inclisiran [Leqvio] |
MP-RX-FP-53-23 |
| Libtayo |
cemiplimab-rwlc |
J9119 |
Cemiplimab-rwlc (Libtayo®) |
MP-RX-FP-54-23 |
| Monoferric |
Ferric derisomaltose |
J1437 |
Iron Agents |
MP-RX-FP-44-23 |
| Monovisc |
Hyaluronan |
J7327 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Mvasi |
Bevacizumab |
Q5107 |
Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) |
MP-RX-FP-13-23 |
| MYCOPHENOLATE MOFETIL ORAL |
Mycophenolate mofetil |
J7517 |
Immunosuppressive Drugs |
LCD - Immunosuppressive Drugs (L33824) (cms.gov) |
| MYCOPHENOLATE SODIUM |
Mycophenolic acid |
J7518 |
Immunosuppressive Drugs |
LCD - Immunosuppressive Drugs (L33824) (cms.gov) |
| Myobloc |
RimabotulinumtoxinB |
J0587 |
Botulinum Toxins |
LCD: L33274 - Botulinum Toxins |
| Leukine |
Sargramostim |
J2820 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Neulasta |
Pegfilgrastim |
J2506 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Neupogen |
Filgrastim |
J1442 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Nivestym |
Filgrastim-aafi |
Q5110 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Novoeight |
Antihemophilic Factor VIII (Recombinant) BD Truncated (BD trunc-rFVIII) |
J7182 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Qfitlia |
Fitusiran Sodium |
J7209 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| NovoSeven RT |
Coagulation Factor VIIa (Recombinant) |
J7189 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Nplate |
Romiplostim |
J2796 |
Romiplostim (Nplate) |
MP-RX-FP-63-23 |
| Nucala |
Mepolizumab |
J2182 |
Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] |
MP-RX-FP-58-23 |
| Nuwiq |
Antihemophilic Factor (Rcmb) Simoctocog alfa(BDD-rFVIII,sim) |
J7209 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Nyvepria |
Pegfilgrastim-apgf |
Q5122 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Rolvedon |
Eflapegrastim-xnst |
J1449 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Obizur |
Antihemophilic Factor (Recombinant Porcine) (rpFVIII) |
J7188 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Ocrevus Zunovo |
Ocrelizumab hyaluronidase |
J3590 |
Ocrelizumab [Ocrevus®], Ocrelizumab/hyaluronidase-ocsq [Ocrevus Zunovo®] |
MP-RX-FP-64-23 |
| Ocrevus |
Ocrelizumab |
J2350 |
Ocrelizumab [Ocrevus®], Ocrelizumab/hyaluronidase-ocsq [Ocrevus Zunovo®] |
MP-RX-FP-64-23 |
| Orencia |
Abatacept |
J0129 |
Orencia (abatacept) |
MP-RX-FP-68-23 |
| Orthovisc |
Hyaluronan |
J7324 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Ozurdex |
Dexamethasone intravitreal implant |
J7312 |
Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] |
MP-RX-FP-43-23 |
| Padcev |
Enfortumab |
J9177 |
Enfortumab vedotin-ejfv (Padcev®) |
MP-RX-FP-70-23 |
| Panzyga |
Ivig non-lyophilized, nos |
J1599 |
Immunoglobulins |
MP-RX-FP-40-23 |
| Privigen |
Inj ivig privigen 500 mg |
J1459 |
Immunoglobulins |
MP-RX-FP-40-23 |
| Procrit |
Epoetin alfa, non-esrd |
J0885 |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Procrit |
Epoetin alfa, 100 units esrd |
Q4081 |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Profilnine |
Factor IX Complex |
J7194 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Prolastin |
Alpha1-Proteinase Inhibitor (Human) |
J0256 |
Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] |
MP-RX-FP-06-23 |
| Radicava |
Edaravone |
J1301 |
Radicava (edaravone) |
MP-RX-FP-75-23 |
| Rebinyn |
Coagulation Factor IX (Recombinant) Glycopegylated |
J7203 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| QFITLIA |
Fitusiran Sodium |
C9399, J3490 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Reblozyl |
Luspatercept-aamt |
J0896 |
Luspatercept (Reblozyl) |
MP-RX-FP-76-23 |
| Recombinate |
Antihemophilic Factor (Recombinant) |
J7192 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Remicade |
Infliximab |
J1745 |
Tumor Necrosis Factor Antagonists |
MP-RX-FP-96-23 |
| Renflexis |
Infliximab-abda |
Q5104 |
Tumor Necrosis Factor Antagonists |
MP-RX-FP-96-23 |
| Retacrit |
Inj retacrit esrd on dialysi |
Q5105 |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Retisert |
Fluocinolone acetonide intravitreal implant |
J7311 |
Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] |
MP-RX-FP-43-23 |
| Riabni |
Rituximab |
Q5123 |
Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications |
MP-RX-FP-78-23 |
| RiaSTAP |
Fibrinogen Concentrate (Human) |
J7178 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Rituxan |
Rituximab |
J9312 |
Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications |
MP-RX-FP-78-23 |
| Rituxan Hycela |
Rituximab |
J9311 |
Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications |
MP-RX-FP-78-23 |
| Rixubis |
Coagulation Factor IX (Recombinant) |
J7200 |
Agents for Hemophilia B |
MP-RX-FP-03-23 |
| Ruconest |
C1 Esterase Inhibitor (Recombinant) |
J0596 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| Ruxience |
Rituximab |
Q5119 |
Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications |
MP-RX-FP-78-23 |
| Sajazir |
Icatibant Acetate |
J1744 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| SandoSTATIN |
Octreotide injection, non-depot |
J2354 |
Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) |
MP-RX-FP-65-23 |
| SandoSTATIN LAR Depot |
Octreotide injection, depot |
J2353 |
Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) |
MP-RX-FP-65-23 |
| Saphnelo |
Anifrolumab-fnia |
J0491 |
Saphnelo (anifrolumab-fnia) |
MP-RX-FP-80-23 |
| SevenFact |
Coagulation Factor VIIa (Recombinant)-jncw |
J7212 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Hympavzi |
marstacimab-hncq |
C9304 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Alhemo |
concizumab-mtci |
C9399, J3590 |
Select Clotting Agents for Bleeding Disorders |
MP-RX-FP-82-23 |
| Simponi Aria |
Golimumab |
J1602 |
Tumor Necrosis Factor Antagonists |
MP-RX-FP-96-23 |
| Skyrizi IV |
Risankizumab-rzaa |
J2327 |
Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] |
MP-RX-FP-61-23 |
| Soliris |
Eculizumab |
J1300 |
Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) |
MP-RX-FP-19-23 |
| Epysqli |
eculizumab-aagh |
J3590 |
Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) |
MP-RX-FP-19-23 |
| Somatuline Depot |
Lanreotide Acetate |
J1930 |
Lanreotide (Somatuline Depot) |
MP-RX-FP-83-23 |
| Spinraza |
Nusinersen |
J2326 |
Spinraza (nusinersen) |
MP-RX-FP-84-23 |
| Stelara IV |
Ustekinumab, iv inject, 1 mg |
J3358 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Wezlana |
Ustekinumab, iv inject, 1 mg |
J3358, Q5137, Q5138 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Selarsdi |
Ustekinumab, iv inject, 1 mg |
J3358 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Pyzchiva |
Ustekinumab, iv inject, 1 mg |
J3358 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Imuldosa |
Ustekinumab, iv inject, 1 mg |
J3358 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Otulfi |
Ustekinumab-aauz |
Q9999 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Yesintek |
Ustekinumab-kfce |
Q5100 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Steqeyma |
Ustekinumab-stba |
Q5099 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Starjemza |
ustekinumab-hmny |
J3490, J3590 |
Ustekinumab agents |
MP-RX-FP-85-23 |
| Syfovre |
Pegcetacoplan |
J2781 |
Syfovre (pegcetacoplan) |
MP-RX-FP-86-23 |
| Sylvant |
Siltuximab |
J2860 |
Sylvant (siltuximab) |
MP-RX-FP-87-23 |
| Synojoynt |
Sodium Hyaluronate (Viscosupplement) |
J7331 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Synvisc |
Hylan |
J7325 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Synvisc-One |
Hylan |
J7325 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| TACROLIMUS IMME REL ORAL 1MG |
Tacrolimus immediate release |
J7507 |
Immunosuppressive Drugs |
LCD - Immunosuppressive Drugs (L33824) (cms.gov) |
| Takhzyro |
Lanadelumab-flyo |
J0593 |
Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo |
MP-RX-FP-36-23 |
| Tepezza |
Teprotumumab-trbw |
J3241 |
Teprotumumab-trbw (Tepezza) |
MP-RX-FP-89-23 |
| Tezspire |
Tezepelumab-ekko |
J2356 |
Tezepelumab-ekko (Tezspire) |
MP-RX-FP-90-23 |
| Tevimbra |
tislelizumab-jsgr |
J3590, J9999 |
Tevimbra_PartB_MedPol_2024 |
MP-RX-FP-155-24 |
| Tremfya |
Guselkumab |
J1628 |
Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] |
MP-RX-FP-61-23 |
| Triesence |
Triamcinolone acetonide preservative-free |
J3300 |
Triamcinolone acetonide injectable suspension [Xipere, Triesence] |
MP-RX-FP-93-23 |
| Triferic |
Ferric pyrophosphate citrate |
J1443 |
Iron Agents |
MP-RX-FP-44-23 |
| Triferic AVNU |
Ferric pyrophosphate citrate |
J1445 |
Iron Agents |
MP-RX-FP-44-23 |
| Triluron |
Sodium Hyaluronate (Viscosupplement) |
J7332 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Trivisc |
Sodium Hyaluronate (Viscosupplement) |
J7329 |
Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] |
MP-RX-FP-38-23 |
| Trogarzo |
Ibalizumab-uiyk |
J1746 |
Ibalizumab-uiyk (Trogarzo) |
MP-RX-FP-95-23 |
| Truxima |
Rituximab |
Q5115 |
Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications |
MP-RX-FP-78-23 |
| Tymlos |
Abaloparatide |
C9399; J3490; J3590 |
Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) |
MP-RX-FP-37-23 |
| Tyruko |
Natalizumab-sztn |
Q5134 |
Natalizumab Agents (Tysabri, Tyruko) |
MP-RX-FP-97-23 |
| Tysabri |
Natalizumab |
J2323 |
Natalizumab Agents (Tysabri, Tyruko) |
MP-RX-FP-97-23 |
| Udenyca |
Pegfilgrastim-cbqv |
Q5111 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Ultomiris |
Ravulizumab-cwvz |
J1303 |
Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) |
MP-RX-FP-19-23 |
| Uplizna |
Inebilizumab-cdon |
J1823 |
Uplizna (inebilizumab-cdon) |
MP-RX-FP-98-23 |
| Venofer |
Iron sucrose |
J1756 |
Iron Agents |
MP-RX-FP-44-23 |
| Vimizim |
Elosulfase Alfa |
J1322 |
Vimizim (elosulfase alfa) |
MP-RX-FP-102-23 |
| Visudyne |
Verteporfin |
J3396 |
Verteporfin [Visudyne] |
MP-RX-FP-101-23 |
| Vonvendi |
Von Willebrand Factor (Recombinant) |
J7179 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Vpriv |
Velaglucerase Alfa |
J3385 |
Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) |
MP-RX-FP-29-23 |
| Vyepti |
Eptinezumab-jjmr |
J3032 |
Eptinezumab-jjmr (Vyepti) |
MP-RX-FP-103-23 |
| Wilate |
Antihemophilic Factor/von Willebrand Factor Complex (Human) |
J7183 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Xeomin |
IncobotulinumtoxinA |
J0588 |
Botulinum Toxins |
LCD: L33274 - Botulinum Toxins |
| Xiaflex |
Collagenase Clostridium Histolyticum |
J0775 |
Xiaflex (collagenase clostridium histolyticum) injection |
MP-RX-FP-104-23 |
| Xipere |
Triamcinolone acetonide |
J3299 |
Triamcinolone acetonide injectable suspension [Xipere, Triesence] |
MP-RX-FP-93-23 |
| Xolair |
Omalizumab |
J2357 |
Omalizumab [Xolair] |
MP-RX-FP-105-23 |
| OMLYCLO |
omalizumab-igec |
J2357 |
Omalizumab [Xolair] |
MP-RX-FP-105-23 |
| Xyntha Solofuse |
Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) |
J7192 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Xyntha |
Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) |
J7185 |
Agents for Hemophilia A and Von Willebrand Disease |
MP-RX-FP-02-23 |
| Yutiq |
Fluocinolone acetonide intravitreal implant |
J7314 |
Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] |
MP-RX-FP-43-23 |
| Zaltrap |
Aflibercept |
J9400 |
Ziv-aflibercept (Zaltrap®) |
MP-RX-FP-107-23 |
| Zarxio |
Filgrastim-sndz |
Q5101 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Zemaira |
Alpha1-Proteinase Inhibitor (Human) |
J0256 |
Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] |
MP-RX-FP-06-23 |
| Fylnetra |
pegfilgrastim-pbbk |
Q5130 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Nypozi |
filgrastim-txid |
C9399, J3590 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Releuko |
filgrastim-ayow |
Q5125 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Stimufend |
pegfilgrastim-fpgk |
Q5127 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Ziextenzo |
Pegfilgrastim-bmez |
Q5120 |
Colony Stimulating Factors |
MP-RX-FP-18-23 |
| Zinplava |
Bezlotoxumab |
J0565 |
Bezlotoxumab (Zinplava) |
MP-RX-FP-109-23 |
| Zirabev |
Bevacizumab |
Q5118 |
Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) |
MP-RX-FP-13-23 |
| Breyanzi |
Lisocabtagene maraleucel |
Q2054 |
Lisocabtagene maraleucel (Breyanzi®) |
NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy |
| Carvykti |
Ciltacabtagene autoleucel |
Q2056 |
Ciltacabtagene autoleucel (Carvykti®) |
NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy |
| Kymriah |
Tisagenlecleucel |
Q2042 |
Tisagenlecleucel (Kymriah®) |
NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy |
| Alymsys |
bevacizumab-maly |
Q5126 |
Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) |
MP-RX-FP-13-23 |
| Jobevne |
bevacizumab-maly |
Q5126 |
Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) |
MP-RX-FP-13-23 |
| Avzivi |
bevacizumab-tnjn |
J3490, J3590 |
Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) |
MP-RX-FP-13-23 |
| Vegzelma |
bevacizumab-adcd |
Q5129 |
Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) |
MP-RX-FP-13-23 |
| Ahzantive |
aflibercept-mrbb |
J3590 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Alymsys intravitreal |
bevacizumab-maly |
Q5126 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Avastin intravitreal |
bevacizumab |
J9035 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Beovu |
Brolucizumab-dbll |
J0179 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Byooviz |
ranibizumab-nuna |
Q5128 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Cimerli |
ranibizumab-eqrn |
Q5124 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Enzeevu |
aflibercept-abzv |
J3590 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Eylea |
Aflibercept |
J0178 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Lucentis |
Ranibizumab |
J2778 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Mvasi intravitreal |
bevacizumab-awwb |
Q5107 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Susvimo |
Ranibizumab |
J2779 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Vabysmo |
Faricimab-svoa |
J2777 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Vegzelma intravitreal |
bevacizumab-adcd |
Q5129 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Zirabev intravitreal |
bevacizumab-bvzr |
Q5118 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23 |
| Izervay |
Avacincaptad Pegol |
C9160 |
Avacincaptad pegol intravitreal solution (Izervay®) |
MP-RX-FP-117-24
|
| Adakveo |
Crizanlizumab-tmca |
J0791 |
Crizanlizumab-tmca (Adakveo®) |
MP-RX-FP-118-24
|
| Jemperli |
Dostarlimab-gxly |
J9272 |
Dostarlimab-gxly (Jemperli®) |
MP-RX-FP-119-24
|
| Elrexfio |
Elranatamab-bcmm |
J3490, J3590, J9999, C9165 |
Elranatamab-bcmm (Elrexfio®) |
MP-RX-FP-120-24
| Epkinly |
Epcoritamab-bysp |
J9321 |
Epcoritamab-bysp (Epkinly®) |
MP-RX-FP-121-24
|
| Columvi |
Glofitamab-gxbm |
J9286 |
Glofitamab-gxbm (Columvi®) |
MP-RX-FP-122-24
|
| Boniva |
Ibandronate sodium injection |
J1740 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Conexxence |
denosumab-bnht |
C9399, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Ospomyv |
denosumab-dssb |
C9399, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Stoboclo |
denosumab-bmwo |
C9399, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Bomyntra |
denosumab-bnht |
C9399, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Xbryk |
denosumab-dssb |
C9399, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Osenvelt |
denosumab-bmwo |
C9399, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Prolia |
Denosumab |
J0897 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Jubbonti |
denosumab-bbdz |
Q5136, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Wyost |
denosumab-bbdz |
Q5136, J3590 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Xgeva |
Denosumab |
J0897 |
IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis |
MP-RX-FP-123-24
|
| Lumizyme |
alglucosidase alfa |
J0221 |
Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®) |
MP-RX-FP-124-24
|
| Nexviazyme |
avalglucosidase alfa-ngpt |
J0219 |
Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®) |
MP-RX-FP-124-24
|
| Pombiliti |
cipaglucosidase alfa-atga |
J3490, J3590, S9357 |
Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®) |
MP-RX-FP-124-24
|
| Omvoh |
Mirikizumab-mrkz |
J3590 |
Mirikizumab-mrkz (Omvoh®) |
MP-RX-FP-125-24
|
| Elahere |
Mirvetuximab Soravtansine-gynx |
J9063 |
Mirvetuximab soravtansine-gynx (Elahere®) |
MP-RX-FP-126-24
|
| Poteligeo |
mogamulizumab-kpkc, 1 mg |
J9204 |
Mogamulizumab-kpkc (Poteligeo®) |
MP-RX-FP-127-24
|
| Mozobil |
plerixafor |
J2562 |
Plerixafor (Mozobil®) |
MP-RX-FP-128-24
|
| Danyelza |
Naxitamab-gqgk |
J9348 |
Naxitamab-gqgk (Danyelza®) |
MP-RX-FP-129-24
|
| Zometa |
Zoledronic |
J3489 |
Zoledronic acid (Zometa®) |
MP-RX-FP-130-24
|
| Portrazza |
necitumumab, 1 mg |
J9295 |
Necitumumab (Portrazza®) |
MP-RX-FP-131-24
|
| Arzerra |
Ofatumumab |
J9302 |
Ofatumumab (Arzerra®) |
MP-RX-FP-132-24
|
| kimyrsa |
oritavancin, 10mg |
J2406 |
Oritavancin (Orbactiv®, Kimyrsa®) |
MP-RX-FP-133-24
|
| orbactiv |
oritavancin, 10mg |
J2407 |
Oritavancin (Orbactiv®, Kimyrsa®) |
MP-RX-FP-133-24
|
| Signifor |
Pasireotide Diaspartate |
C9399, J3490, J3590 |
Pasireotide (Signifor®, Singnifor LAR®) |
MP-RX-FP-134-24
|
| Signifor LAR |
Pasireotide Pamoate |
J2502 |
Pasireotide (Signifor®, Singnifor LAR®) |
MP-RX-FP-134-24
|
| Empaveli |
Pegcetacoplan |
J3490, C9399 |
Pegcetacoplan (Empaveli®) |
MP-RX-FP-135-24
|
| Veopoz |
Pozelimab-bbfg |
J3590, C9399 |
Pozelimab-bbfg (Veopoz®) |
MP-RX-FP-136-24
|
| Azedra |
iobenguane I 131 |
A9590 |
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) |
MP-RX-FP-137-24
|
| Lutathera |
lutetium Lu 177 dotatate |
A9513 |
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) |
MP-RX-FP-137-24
|
| Pluvicto |
Lutetium lu 177 vipivotide tetraxetan |
A9607 |
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) |
MP-RX-FP-137-24
|
| Zevalin Y-90 |
Ibritumomab Tiuxetan |
A9543 |
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) |
MP-RX-FP-137-24
|
| Zynyz |
Retifanlimab-dlwr |
J9345 |
Retifanlimab-dlwr (Zynyz®) |
MP-RX-FP-138-24
|
| Ryzneuta |
efbemalenograstim alfa-vuxw |
J3490, J3590 |
Colony Stimulating Factors |
MP-RX-FP-18-23
|
| Spevigo |
Spesolimab-sbzo |
J1747 |
Spesolimab-sbzo (Spevigo®) |
MP-RX-FP-140-24
|
| Enjaymo |
Sutimlimab-jome |
J1302 |
Sutimlimab-jome (Enjaymo®) |
MP-RX-FP-141-24
|
| Talvey |
Talquetamab-tgvs |
J3490, J3590, J9999, C9163 |
Talquetamab-tgvs (Talvey®) |
MP-RX-FP-142-24
|
| Kimmtrak |
Tebentafusp-tebn |
J9274 |
Tebentafusp-tebn (Kimmtrak®) |
MP-RX-FP-143-24
|
| Tecvayli |
Teclistamab-cqyv |
J9380 |
Teclistamab-cqyv (Tecvayli®) |
MP-RX-FP-144-24
|
| Tivdak |
Tisotumab Vedotin-tftv |
J9273 |
Tisotumab vedotin-tftv (Tivdak®) |
MP-RX-FP-145-24
|
| Qalsody |
Tofersen |
J1304 |
Tofersen (Qalsody®) |
MP-RX-FP-146-24
|
| Loqtorzi |
Toripalimab-tpzi |
J3490, J3590, C9399 |
Toripalimab-tpzi (Loqtorzi®) |
MP-RX-FP-147-24
|
| Yondelis |
Trabectedin |
J9352 |
Trabectedin (Yondelis®) |
MP-RX-FP-148-24
|
| Adbry |
Tralokinumab-ldrm |
J3490, J3590, C9399 |
Tralokinumab-ldrm (Adbry®) |
MP-RX-FP-149-24
|
| Imjudo |
Tremelimumab-actl |
J9347 |
Tremelimumab-actl (Imjudo®) |
MP-RX-FP-150-24
|
| Briumvi |
ublituximab-xiiy |
J2329 |
Ublituximab-xiiy (Briumvi®) |
MP-RX-FP-151-24
|
| Reclast |
Zoledronic |
J3489 |
Zoledronic acid (Reclast®) |
MP-RX-FP-152-24
|
| Yervoy |
Ipilimumab |
J9228 |
Ipilimumab (Yervoy®) |
MP-RX-FP-106-23
|
| Zepzelca |
Lurbinectedin |
J9223 |
Lurbinectedin (Zepzelca®) |
MP-RX-FP-108-23
|
| Zynlonta |
loncastuximab tesirine-lpyl |
J9359 |
Loncastuximab tesirine-lpyl (Zynlonta®) |
MP-RX-FP-110-23
|
| Camcevi |
Leuprolide mesylate |
J1952 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Eligard |
Leuprolide |
J9217 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Fensolvi |
Leuprolide |
J1951 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Firmagon |
Firmagon |
J9155 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Firmagon (240 MG Dose) |
Degarelix |
J9155 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Lupaneta |
Leuprolide |
J1950 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Lupron Depot (1-Month) |
Leuprolide |
J1950 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Lupron Depot (3-Month) |
Leuprolide |
J9217 (Non-Oncology), J1950 (Oncology) |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Lupron Depot (6-Month) |
Leuprolide |
J9217 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Supprelin |
Leuprolide |
J9217 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| TRELSTAR |
Triptorelin |
J3315 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Triptodur |
Triptorelin pamoate extended-release |
J3316 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Zoladex |
Goserelin |
J9202 |
GnRH analogs for non-oncology and oncology-related indications |
MP-RX-FP-34-23
|
| Asceniv |
|
J3590 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Octagam |
Immune Globulin (Human) IV |
|
Immunoglobulins |
MP-RX-FP-40-23
|
| Gammaplex |
Immune Globulin (Human) IV |
J3590 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Gammaked |
Immune Globulin (Human) IV |
J3590 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Flebogamma DIF |
Immune Globulin (Human) IV |
J3590 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Cuvitru |
Immune Globulin (Human) Subcutaneous |
J3590 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Bivigam |
Immune Globulin (Human) IV |
J3590 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Cutaquig |
Immune Globulin (Human) IV |
J1551 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Hizentra |
Immune Globulin (Human) IV |
J1559 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Xembify |
Immune Globulin (Human) IV |
J1558 |
Immunoglobulins |
MP-RX-FP-40-23
|
| Hercessi |
trastuzumab-strf |
J3590 |
Trastuzumab – Trastuzumab Biologics |
MP-RX-FP-161-24
|
| IXEMPRA |
Ixabepilone |
J9207 |
Ixabepilone (Ixempra®) |
MP-RX-FP-46-23
|
| Margenza |
Margetuximab |
J9353 |
Margetuximab-cmkb (Margenza®) |
MP-RX-FP-56-23
|
| Monjuvi |
Tafasitamab |
J9349 |
Tafasitamab-cxix (Monjuvi®) |
MP-RX-FP-57-23
|
| Mylotarg |
gemtuzumab ozogamicin |
J9203 |
Gemtuzumab ozogamicin (Mylotarg®) |
MP-RX-FP-62-23
|
| Sarclisa |
Isatuximab |
J9227 |
isatuximab (Sarclisa®) |
MP-RX-FP-81-23
|
| Torisel |
Temsirolimus |
J9330 |
Temsirolimus (Torisel®) |
MP-RX-FP-91-23
|
| Vectibix |
Panitumumab |
J9303 |
Panitumumab (Vectibix®) |
MP-RX-FP-99-23
|
| Adcetris |
Brentuximab |
J9042 |
Brentuximab vedotin (Adcetris®) |
MP-RX-FP-01-23
|
| Alimta |
Pemetrexed |
J9305 |
Pemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®) |
MP-RX-FP-05-23
|
| Pemetrexed |
Pemetrexed |
J9314, J9322, J9323, J9294, J9296, J9297 |
Pemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®) |
MP-RX-FP-05-23
|
| Pemfexy |
Pemetrexed |
J9304 |
Pemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®) |
MP-RX-FP-05-23
|
| Pemrydi |
Pemetrexed |
J9324 |
Pemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®) |
MP-RX-FP-05-23
|
| Axtle |
Pemetrexed |
J9292 |
Pemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®) |
MP-RX-FP-05-23
|
| Bavencio |
Avelumab |
J9023 |
Avelumab (Bavencio®) |
MP-RX-FP-09-23
|
| Belrapzo |
Bendamustine |
J9036 |
Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) |
MP-RX-FP-10-23
|
| Bendeka |
Bendamustine |
J9034, J9058, J9059 |
Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) |
MP-RX-FP-10-23
|
| Treanda |
Bendamustine |
J9033 |
Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) |
MP-RX-FP-10-23
|
| Vivimusta |
Bendamustine |
J9056 |
Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) |
MP-RX-FP-10-23
|
| Abecma |
Idecabtagene vicleucel |
Q2055 |
Idecabtagene vicleucel (Abecma®) |
NCD - Chimeric Antigen Receptor (CAR) T-cell Therapy (110.24) (cms.gov)
|
| Tecartus |
Brexucabtagene autoleucel |
Q2053 |
Brexucabtagene autoleucel (Tecartus®) |
NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy |
| Yescarta |
axicabtagene ciloleucel |
Q2041 |
Axicabtagene ciloleucel (Yescarta®) |
NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy |
| Besponsa |
Inotuzumab |
J9229 |
Inotuzumab ozogamicin (Besponsa®) |
MP-RX-FP-12-23
|
| Blincyto |
Blinatumomab |
J9039 |
Blinatumomab (Blyncito®) |
MP-RX-FP-14-23
|
| Cyramza |
Ramucirumab |
J9308 |
Ramucirumab (Cyramza®) |
MP-RX-FP-20-23
|
| Empliciti |
Elotuzumab |
J9176 |
Elotuzumab (Empliciti®) |
MP-RX-FP-26-23
|
| Erbitux |
Cetuximab |
J9055 |
Cetuximab (Erbitux®) |
MP-RX-FP-30-23
|
| Halaven |
Eribulin |
J9179 |
Eribulin mesylate (Halaven®) |
MP-RX-FP-35-23
|
| Imfinzi |
Durvalumab |
J9173 |
Durvalumab (Imfinzi®) |
MP-RX-FP-39-23
|
| Jevtana |
Cabazitaxel |
J9043, J9064 |
Cabazitaxel (Jevtana®) |
MP-RX-FP-47-23
|
| Kadcyla |
ado-trastuzumab emtansine |
J9354 |
Ado-trastuzumab (Kadcyla®) |
MP-RX-FP-48-23
|
| Kyprolis |
Carfilzomib |
J9047 |
Carfilzomib (Kyprolis®) |
MP-RX-FP-51-23
|
| Lunsumio |
mosunetuzumab-axgb |
J9350 |
Mosunetuzumab-axgb (Lunsumio®) |
MP-RX-FP-55-23
|
| Opdivo |
Nivolumab |
J9299 |
Nivolumab (Opdivo®) and Nivolumab and hyaluronidase-nvhy (Opdivo Qvantig®) |
MP-RX-FP-66-23
|
| Opdivo Qvantig |
Nivolumab and hyaluronidase-nvhy |
J9999 |
Nivolumab (Opdivo®) and Nivolumab and hyaluronidase-nvhy (Opdivo Qvantig®) |
MP-RX-FP-66-23
|
| Polivy |
Polatuzumab |
J9309 |
Polatuzumab vedotin-piiq (Polivy®) |
MP-RX-FP-73-23
|
| Opdualag |
nivolumab and relatlimab-rmbw |
J9298 |
Nivolumab and relatlimab-rmbw (Opdualag®) |
MP-RX-FP-67-23
|
| Abraxane |
Paclitaxel |
J9264 |
Paclitaxel, Protein Bound (Abraxane®) |
MP-RX-FP-69-23
|
| PACLitaxel Protein-Bound Part |
Paclitaxel |
J9264 |
Paclitaxel, Protein Bound (Abraxane®) |
MP-RX-FP-69-23
|
| Perjeta |
Pertuzumab |
J9306 |
Pertuzumab (Perjeta®) |
MP-RX-FP-71-23
|
| Rybrevant |
amivantamab-vmjw |
J9061 |
Amivantamab-vmjw (Rybrevant®) |
MP-RX-FP-79-23
|
| Tecentriq |
Atezolizumab |
J9022 |
Atezolizumab (Tecentriq), Atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) |
MP-RX-FP-88-23
|
| Tecentriq Hybreza |
Atezolizumab and hyaluronidase-tqjs |
J9024 |
Atezolizumab (Tecentriq), Atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) |
MP-RX-FP-88-23
|
| Trodelvy |
Sacituzumab |
J9317 |
Sacituzumab govitecan (Trodelvy®) |
MP-RX-FP-94-23
|
| Niktimvo |
Axatilmab-csfr |
J3590, C9399 |
Axatilmab-csfr (Niktimvo) |
MP-RX-FP-159-24
|
| Pedmark |
Sodium Thiosulfate (Otoprotective) |
J0208 |
Sodium thiosulfate injection (Pedmark) |
MP-RX-FP-160-24
|
| Herzuma |
Trastuzumab-pkrb |
Q5113 |
Trastuzumab Agents |
MP-RX-FP-161-24
|
| Kanjinti |
Trastuzumab |
Q5117 |
Trastuzumab Agents |
MP-RX-FP-161-24
|
| Ogivri |
Trastuzumab-dkst |
Q5114 |
Trastuzumab Agents |
MP-RX-FP-161-24
|
| Ontruzant |
trastuzumab-dttb |
Q5112 |
Trastuzumab Agents |
MP-RX-FP-161-24
|
| Phesgo |
pertuzumab, trastuzumab, and hyaluronidase-zzxf |
J9316 |
Trastuzumab Agents |
MP-RX-FP-161-24
|
| Trazimera |
Trastuzumab-qyyp |
Q5116 |
Trastuzumab Agents |
MP-RX-FP-161-24
|
| Vyloy |
Zolbetuximab-clzb |
J3590, C9399, J9999 |
Zolbetuximab-clzb (Vyloy) |
MP-RX-FP-162-24
|
| Elevidys |
Delandistrogene moxeparvovec-rokl |
J1413 |
Delandistrogene moxeparvovec-rokl (Elevidys) |
MP-RX-FP-163-24
|
| Vyalev |
Levodopa Combinations |
J7799 |
Foscarbidopa and Foslevodopa (Vyalev) |
MP-RX-FP-164-24
|
| Vyafuser |
Subcutaneous Infusion Pump |
E0781, E1399 |
Foscarbidopa and Foslevodopa (Vyalev) |
MP-RX-FP-164-24
|
| Cosentyx |
Secukinumab |
C9399; J3490; J3590 |
Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] |
MP-RX-FP-60-23
|
| Siliq |
brodalumab |
C9399; J3490; J3590 |
Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] |
MP-RX-FP-60-23
|
| Taltz |
Ixekizumab |
C9399; J3490; J3590 |
Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] |
MP-RX-FP-60-23
|
| Adacel |
Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap) |
90715 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| Boostrix |
Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap) |
90715 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| Tetanus-Diphtheria Toxoids Td |
Tetanus-Diphtheria Toxoids (Td) |
90714 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| Engerix-B |
Hepatitis B Vaccine (Recomb) |
90756 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| Heplisav-B |
Hepatitis B Vaccine Recombinant Adjuvanted |
90739 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| PreHevbrio |
Hepatitis B Vaccine 3-Antigen Recombinant |
90759 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| Recombivax HB |
Hepatitis B Vaccine (Recomb) |
90746 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| Twinrix |
Hepatitis A (Inactivated)-Hepatitis B (Recombinant) Vaccines |
90636 |
Hepatitis B and Tetanus-Containing Vaccines |
MP-RX-FP-156-24
|
| Yesafili |
aflibercept |
J3590 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23
|
| Opuviz |
aflibercept |
J3590 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23
|
| Pavblu |
aflibercept-ayyh |
J3590 |
Vascular Endothelial Growth Factor (VEGF) Inhibitors |
MP-RX-FP-100-23
|
| Piasky |
crovalimab-akkz |
J3590 |
Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) |
MP-RX-FP-19-23
|
| Bkemv |
eculizumab |
J3590 |
Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) |
MP-RX-FP-19-23
|
| Tyenne |
tocilizumab-aazg |
C9399 |
Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara), Tofidence (Tocilizumab-bavi) |
MP-RX-FP-59-23
|
| Tofidence |
Tocilizumab-bavi |
J5133 |
Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara), Tofidence (Tocilizumab-bavi) |
MP-RX-FP-59-23
|
| Rytelo |
Imetelstat |
C9399; J3490; J9999 |
Imetelstat (Rytelo) |
MP-RX-FP-157-24
|
| Rystiggo |
Rozanolixizumab-noli |
J9333 |
Rozanolixizumab-noli (Rystiggo) |
MP-RX-FP-168-25
|
| Lymphir |
Denileukin diftitox-cxdl |
C9399; J3490; J9999 |
Denileukin diftitox-cxdl (Lymphir) |
MP-RX-FP-158-24
|
| Leqembi |
Lecanemab-irmb |
J0174 |
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) |
NCD - Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) (200.3) (cms.gov)
|
| Truvada |
Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg, oral |
J0750 |
Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection |
NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Tracking Sheet (cms.gov)
|
| Descovy |
Emtricitabine 200 mg and tenofovir alafenamide 25 mg, oral |
J0751 |
Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection |
NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Tracking Sheet (cms.gov)
|
| Apretude |
Injection, cabotegravir, 1 mg |
J0739 |
Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection |
NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Tracking Sheet (cms.gov)
|
| Bizengri |
zenocutuzumab-zbco |
C9399, J9999 |
Bizengri (zenocutuzumab-zbco) |
MP-RX-FP-165-25
|
| Kisunla |
Donanemab-azbt |
J0175 |
Donanemab-azbt (Kisunla) |
MP-RX-FP-166-25
|
| Ziihera |
Zanidatamab-hrii |
C9399, J9999 |
Ziihera (Zanidatamab-hrii) |
MP-RX-FP-167-25
|
| Nebupent |
Pentamidine Isethionate |
J2525 |
Pentamidine Isethionate (Nebupent®) |
MP-RX-FP-169-25
|
| BEQVEZ |
Fidanacogene elaparvovec-dzkt |
J1414 |
Fidanacogene elaparvovec-dzkt (BEQVEZ) |
MP-RX-FP-170-25
|
| Imdelltra |
Tarlatamab-dlle |
J9026 |
Tarlatamab-dlle (Imdelltra) |
MP-RX-FP-171-25
|
| Revatio |
Sildenafil Citrate |
J3490 |
Sildenafil Citrate (Revatio) |
MP-RX-FP-172-25
|
| Cosela |
Trilaciclib |
J1448 |
Trilaciclib (Cosela) |
MP-RX-FP-173-25
|
| Grafapex |
Treosulfan |
C9175, J9999 |
Treosulfan (Grafapex) |
MP-RX-FP-174-25
|
| Emrelis |
Telisotuzumab Vedotin-tllv |
C9399, J9999 |
Telisotuzumab vedotin-tllv (Emrelis) |
MP-RX-FP-175-25
|
| Zusduri |
Mitomycin |
J9999, C9399 |
Mitomycin (Zusduri) |
MP-RX-FP-176-25
|
|
