Institutional Cost Report (ICR) Drug Carve Out List by Year

NYS DOH - Never Pay Procedures Under APG Reimbursement

Effective January 1, 2018 - March 31, 2019
Px Code Procedure (Px) Description Alternative Payment Available* Date added to Never Pay List Date Removed from Never Pay List Date subsequently added to Never Pay List Notes
J0365 Injection, aprotonin, 10,000 kiu Yes 01/01/11      
J0480 Injection, basiliximab, 20 mg Yes 01/01/11      
J0585 Botulinum toxin a per unit Yes 12/01/08 01/01/15    
J0587 Botulinum toxin type B Yes 12/01/08      
J0740 Injection, cidofovir, 375 mg Yes 01/01/11      
J0882 Darbepoetin alfa, esrd use Yes 12/01/08 01/01/12    
J0890 Peginesatide injection No 07/01/13      
J1442 Inj filgrastim excl biosimil Yes 01/01/18      
J1566 Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg Yes 01/01/11      
J1675 Injection, histrelin acetate, 10 micrograms Yes 01/01/11      
J1726 Makena, 10 mg Yes 01/01/18      
J1931 Injection, laronidase, 0.1 mg Yes 01/01/11      
J2315 Naltrexone, depot form Yes - Only for Article 32 providers 01/01/10 07/01/11    
J2323 Natalizumab injection Yes - only for TOUCH providers 01/01/10 01/01/11    
J2358 Olanzapine long-acting inj Yes 04/01/11      
J2426 Paliperidone palmitate inj Yes 04/01/11      
J2505 Injection, pegfilgrastim 6mg Yes 12/01/08      
J2562 Injection, plerixafor, 1 mg Yes 01/01/11      
J2794 Risperidone, long acting Yes 04/01/09      
J2997 Alteplase recombinant Yes 04/01/10 04/01/11    
J3110 Injection, teriparatide, 10 mcg Yes 01/01/11      
J3285 Injection, treprostinil, 1 mg Yes 01/01/11      
J3490 Drugs unclassified injection Yes 04/01/10      
J3590 Unclassified biologics Yes 04/01/10      
J7175 Inj, factor x, (human), 1iu Yes 01/01/18      
J7178 Human fibrinogen conc inj Yes 01/01/18      
J7179 Vonvendi inj 1 iu vwf:rco Yes 01/01/18      
J7181 Factor xiii recomb a-subunit Yes 01/01/18      
J7182 Factor viii recomb novoeight Yes 01/01/18      
J7183 Wilate injection Yes 01/01/18      
J7185 Xyntha inj Yes 01/01/18      
J7186 Antihemophilic viii/vwf comp Yes 01/01/18      
J7187 Humate-P, inj Yes 12/01/08      
J7188 Factor viii recomb obizur Yes 01/01/18      
J7189 Factor viia Yes 12/01/08      
J7190 Factor viii Yes 12/01/08      
J7191 Factor VIII (porcine) Yes 12/01/08      
J7192 Factor viii recombinant Yes 12/01/08      
J7193 Factor IX No - APG Carve Outn-recombinant Yes 12/01/08      
J7194 Factor ix complex Yes 12/01/08      
J7195 Factor IX recombinant Yes 12/01/08      
J7196 Antithrombin recombinant Yes 01/01/18      
J7197 Antithrombin iii injection Yes 12/01/08      
J7198 Anti-inhibitor Yes 12/01/08      
J7199 Hemophilia clot factor No - APG Carve Outc Yes 12/01/08      
J7200 Factor ix recombinan rixubis Yes 01/01/18      
J7201 Factor ix alprolix recomb Yes 01/01/18      
J7202 Factor ix idelvion inj Yes 01/01/18      
J7205 Factor viii fc fusion recomb Yes 01/01/18      
J7207 Factor viii pegylated recomb Yes 01/01/18      
J7209 Factor viii nuwiq recomb 1iu Yes 01/01/18      
J7296 Kyleena, 19.5 mg Yes 01/01/18      
J7297 Levonorgestrel iu 52mg 3 yr Yes 07/01/16      
J7298 Levonorgestrel iu 52mg 5 yr Yes 07/01/16      
J7300 Intraut copper contraceptive Yes 12/01/08      
J7301 Levonorgestrel iu 13.5 mg Yes 07/01/16      
J7306 Levonorgestrel implant sys Yes 07/01/16      
J7307 EtoNo - APG Carve Outgestrel implant system Yes 12/01/08      
J7320 Genvisc 850, inj, 1mg No 01/01/17      
J7322 Hymovis injection 1 mg No 01/01/17      
J8520 Capecitabine, oral, 150 mg Yes 01/01/11      
J9019 Erwinaze injection Yes 07/01/14      
J9027 Clofarabine injection Yes 12/01/08      
J9033 Injection, bendamustine hcl, 1 mg Yes 01/01/11      
J9035 Injection, bevacizumab, 10 mg Yes 01/01/11      
J9039 Injection, blinatumomab Yes 01/01/18      
J9055 Injection, cetuximab, 10 mg Yes 01/01/11      
J9098 Injection, cytarabine liposome, 10 mg Yes 01/01/11      
J9120 Injection, dactinomycin, 0.5 mg Yes 01/01/11      
J9160 Injection, denileukin diftitox, 300 micrograms Yes 01/01/11      
J9202 Goserelin acetate implant Yes 01/01/18      
J9207 Injection, ixabepilone, 1 mg Yes 01/01/11      
J9219 Leuprolide acetate implant, 65 mg Yes 01/01/11      
J9225 Histrelin implant (vantas), 50 mg Yes 01/01/11      
J9226 Supprelin LA implant Yes 10/01/10      
J9245 Injection, melphalan hydrochloride, 50 mg Yes 01/01/11      
J9263 Injection, oxaliplatin, 0.5 mg Yes 01/01/11      
J9264 Injection, paclitaxel protein-bound particles, 1 mg Yes 01/01/11      
J9266 Injection, pegaspargase, per single dose vial Yes 01/01/11      
J9268 Injection, pentostatin, 10 mg Yes 01/01/11      
J9271 Inj pembrolizumab Yes 01/01/18      
J9299 Injection, nivolumab Yes 01/01/18      
J9301 Obinutuzumab inj Yes 01/01/18      
J9303 Injection, panitumumab, 10 mg Yes 01/01/11      
J9305 Injection, pemetrexed, 10 mg Yes 01/01/11      
J9307 Pralatrexate injection Yes 01/01/18      
J9308 Injection, ramucirumab Yes 01/01/18      
J9310 Injection, rituximab, 100 mg Yes 01/01/11     No longer a valid code as of 1/1/2019
J9354 Inj, ado-trastuzumab emt 1mg Yes 01/01/18      
J9355 Injection, trastuzumab, 10 mg Yes 01/01/11      
J9400 Inj, ziv-aflibercept, 1mg Yes 01/01/18      
J9600 Injection, porfimer sodium, 75 mg Yes 01/01/11      

*Procedure codes listed as carve outs should not be billed using APGs. Indication as a carve out does not guarantee alternative payment.

NYS DOH - Never Pay APGs Under APG Reimbursement with procedures for that APG

Effective January 1, 2018 - March 31, 2019
APG APG Desc Procedure Code Alternative Payment Available* Date added to Never Pay List Date Removed from Never Pay List Comments
430 Class I Chemotherapy Drugs   Yes - carve out 12/1/2008    
Radiopharm rx agent noc A9699        
Injection, aprepitant C9463       No longer a valid code as of 1/1/2019
Injection, rolapitant C9464       No longer a valid code as of 1/1/2019
Leucovorin calcium injection J0640        
Epoprostenol injection J1325        
Gonadorelin hydroch/ 100 mcg J1620        
Sirolimus, oral J7520        
Capecitabine, oral, 150 mg J8520        
Melphalan oral 2 mg J8600        
Doxorubicin hcl injection J9000        
Bleomycin sulfate injection J9040        
Carboplatin injection J9045        
Cisplatin 10 mg injection J9060        
Dacarbazine 100 mg inj J9130        
Etoposide injection J9181        
Mesna injection J9209        
Interferon alfa-n3 inj J9215        
Paclitaxel injection J9265        
Vinorelbine tartrate inj J9390        
Chemotherapy drug J9999        
Mercaptopurine 50 mg S0108        
Exemestane, 25 mg S0156        
Anastrozole 1 mg S0170        
Chlorambucil 2 mg S0172        
Hydroxyurea 500 mg S0176        
Megestrol 20 mg S0179        
Procarbazine, oral S0182        
Tamoxifen 10 mg S0187        
431 Class II Chemotherapy Drugs   Yes - carve out 12/1/2008    
Aprotonin, 10,000 kiu J0365        
Sincalide injection J2805        
Azathioprine parenteral J7501        
Oral everolimus J7527        
Capecitabine, oral, 500 mg J8521        
Etoposide oral 50 mg J8560        
Bcg live intravesical vac J9031        
Cyclophosphamide 100 mg inj J9070        
Inj, epirubicin hcl, 2 mg J9178        
Fludarabine phosphate inj J9185        
Floxuridine injection J9200        
Irinotecan injection J9206        
Ifosfamide injection J9208        
Topotecan injection J9351        
432 Class III Chemotherapy Drugs   Yes - carve out 12/1/2008    
Oral netupitant palonosetron C9448        
Ibutilide fumarate injection J1742        
Interferon beta-1a inj J1826        
Palonosetron hcl J2469        
Pentastarch 10% solution J2513        
Oral aprepitant J8501        
Temozolomide J8700        
Asparaginase, nos J9020        
Daunorubicin injection J9150        
Daunorubicin citrate inj J9151        
Leuprolide acetate injeciton J9218       This Px code was assigned to APG 430 as of 1/1/2019
Mechlorethamine hcl inj J9230        
Mitoxantrone hydrochl / 5 mg J9293        
Flutamide 125 mg S0175        
433 Class IV Chemotherapy Drugs   Yes - carve out 12/1/2008    
Inj, akynzeo C9033       No longer a valid code as of 1/1/2019
Amifostine J0207       This Px code was assigned to APG 434 as of 1/1/2019
Daptomycin injection J0878        
Quinupristin/dalfopristin J2770        
Inj cladribine per 1 mg J9065        
Degarelix injection J9155        
Docetaxel injection J9171        
Idarubicin hcl injection J9211       This Px code was assigned to APG 432 as of 1/1/2019
Interferon alfa-2b inj J9214        
Streptozocin injection J9320        
Thiotepa injection J9340        
434 Class V Chemotherapy Drugs   Yes - carve out 12/1/2008    
Omacetaxine mepesuccinate C9297        
Levoleucovorin injection J0641        
Ceftaroline fosamil inj J0712       This Px code was assigned to APG 432 as of 1/1/2019
Cidofovir injection J0740        
Corticorelin ovine triflutal J0795        
Eptifibatide injection J1327        
Lepirudin J1945        
Leuprolide acetate /3.75 mg J1950        
Tirofiban hcl J3246        
Triptorelin pamoate J3315       This Px code was assigned to APG 441 as of 1/1/2019
Treprostinil, non-comp unit J7686        
Gefitinib oral J8565        
Arsenic trioxide injection J9017        
Azacitidine injection J9025        
Interferon alfa-2a inj J9213        
Interferon gamma 1-b inj J9216        
Leuprolide acetate suspnsion J9217        
Inj, omacetaxine mep, 0.01mg J9262        
Plicamycin (mithramycin) inj J9270        
Mitomycin injection J9280       This Px code was assigned to APG 441 as of 1/1/2019
Inj, vincristine sul lip 1mg J9371       This Px code was assigned to APG 462 as of 1/1/2019
Imatinib 100 mg S0088        
Lomustine 10 mg S0178        
441 Class VI Chemotherapy Drugs   Yes - carve out 1/1/2010    
Netupitant palonosetron oral J8655       This Px code was assigned to APG 433 as of 1/1/2019
Inj., infliximab biosimilar Q5102        
443 CLASS VII CHEMOTHERAPY DRUGS   Yes - carve out 1/1/2011    
Adalimumab injection J0135        
Denosumab injection J0897        
Dexrazoxane hcl injection J1190        
Palifermin injection J2425        
Pegademase bovine, 25 iu J2504        
Zoledronic acid J3487        
Monoclonal antibodies J7505        
Aldesleukin injection J9015        
Pentostatin injection J9268        
Temozolomide injection J9328        
Temsirolimus injection J9330        
Injection, fulvestrant J9395        
Sermorelin acetate injection Q0515        
465 CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY   Yes - carve out 7/1/2011    
Y90 ibritumomab, rx A9543        
I131 tositumomab, rx A9545        
Radium ra223 dichloride ther A9606        
Injection, cerliponase alfa C9014       No longer a valid code as of 1/1/2019
Inj, triptorelin ext rel C9016       No longer a valid code as of 1/1/2019
Injection, elosulfase alfa C9022        
Lutetium Lu 177 dotatate, tx C9031       No longer a valid code as of 1/1/2019
Voretigene neparvovec-rzyl C9032       No longer a valid code as of 1/1/2019
Factor XIII A-subunit recomb C9134        
Injection, glucarpidase C9293        
Inj, taliglucerase alfa C9294        
Fluocinolone acetonide implt C9450        
Injection, sebelipase alfa C9478        
Injection, atezolizumab C9483        
Injection, eteplirsen C9484        
Injection, nusinersen C9489        
Injection, alemtuzumab J0202        
Alglucosidase alfa injection J0220        
Lumizyme injection J0221        
Injection, ruconest J0596       This Px code was assigned to APG 462 as of 1/1/2019
Canakinumab injection J0638       This Px code was assigned to APG 462 as of 1/1/2019
Eculizumab injection J1300        
Elosulfase alfa, injection J1322        
Inj, eteplirsen, 10 mg J1428        
Galsulfase injection J1458        
Idursulfase injection J1743       This Px code was assigned to APG 464 as of 1/1/2019
Imuglucerase injection J1786        
Inj, nusinersen, 0.1mg J2326        
Injection, ocrelizumab, 1 mg J2350        
Inj sebelipase alfa 1 mg J2840        
Inj, taliglucerace alfa 10 u J3060        
Velaglucerase alfa J3385       This Px code was assigned to APG 464 as of 1/1/2019
Factor xiii anti-hem factor J7180        
Factor viii (porcine) J7191        
Ganciclovir long act implant J7310        
Fluocinolone acetonide implt J7311        
Fluocinol acet intravit imp J7313       This Px code was assigned to APG 464 as of 1/1/2019
Inj, atezolizumab,10 mg J9022        
Brentuximab vedotin inj J9042        
Supprelin la implant J9226        
Ipilimumab injection J9228        
Tisagenlecleucel car-pos t Q2040       No longer a valid code as of 1/1/2019
Axicabtagene ciloleucel car+ Q2041       This Px code was assigned to APG 120 as of 1/1/2019
Sipuleucel-t auto cd54+ Q2043        
inj. emicizumab-kxwh, 0.5 mg Q9995       No longer a valid code as of 1/1/2019
495 MINOR CHEMOTHERAPY DRUGS   Yes - carve out 7/1/2012    
Oral busulfan J8510        
Cabergoline, oral 0.25mg J8515        
Cyclophosphamide oral 25 mg J8530        
Oral dexamethasone J8540        
Methotrexate oral 2.5 mg J8610        
Nabilone oral J8650        
Rolapitant, oral, 1mg J8670        
Cytarabine hcl 100 mg inj J9100        
Fluorouracil injection J9190        
Interferon alfacon-1 inj J9212        
Methotrexate sodium inj J9250        
Methotrexate sodium inj J9260        
Paclitaxel injection J9267        
Vinblastine sulfate inj J9360        
Vincristine sulfate 1 mg inj J9370        
Rolapitant, oral, 1mg Q9981        

*APGs listed as carve outs should not be billed using APGs. Indication as a carve out does not guarantee alternative payment.