Provider Administered Drug Program (PADP) Form

■ Outpatient (On-Campus & Off-Campus) ■ Ambulatory Surgery Center (ACS) ■ BlueSelect (Group & Individual) ■ State Account Employees ■ BlueChoice (Group & Individual) ■ Effective 07/01/2021, Medicare Adv HMO & PPO will no longer be managed by MRxM Management ■ SimplyBlue (excluding out of state and Non-Par Providers) Provider Administered Drug Program (PADP) - Managed by Magellan Rx Management January 2026 Excluded from MRxM Management ■ Medicare Part B Primary Place of Services Included MRxM Management ■ BlueOptions (Group & Individual) ■ Office ■ Ambulatory Infusion Suite (AIS) ■ Other Outpatient Centers Products Included in MRxM Management Florida Blue and Health Options, Inc has contracted with Prime Therapeutics Management MPS division (formerly known as: Magellan Rx Management MRxM/ ICORE) to assist in managing the Provider Administered Drug Program (PADP) which includes a select set of physician/ healthcare professional administered medication. The utilization management program is designated to maximize patient care in the most appropriate and affordable manner based on clinically accepted standards. As with all utilization management programs, PADP will be utilized to determine if the proposed service meets the definition of medical necessity under the member's benefit plan. PADP has been in place and managed by Prime Therapeutics Management MPS division (formerly known as: Magellan Rx Management MRxM/ ICORE) since July 2009 with periodic drug updates. Beginning November 14, 2016, Prime Therapeutics Management MPS division (formerly known as: Magellan Rx Management MRxM/ ICORE) began performing and issuing the prior authorizations (required based on the Member and/or Provider contract), Voluntary Pre-determinations for Select Services (VPSS), and/ or Advanced Organizational Determinations (SAO) for the designated drugs included in the PADP Drug list for all provider/ facility types (In-State and Out of State) that will be administering the medication within the following place of services for the included products identified below (see below for limited exclusions) :
■ Home ■ Clinics ■ HOI BlueCare (excluding out of state and Non-Par Providers) ■ My Blue (excluding out of state and Non-Par Providers) ■ Miami Dade (Group & Individual) PADP has been in place and managed by Prime Therapeutics Management MPS division (formerly known as: Magellan Rx Management MRxM/ ■ FEP (Federal Employee Program), BlueCard Host, Be Healthy, Medicare Advantage HMO & PPO and Medicare Supplement ■ CareCentrix Providers when In-State Home or AIS (Prior Auth will be performed through CareCentrix) ■ Drugs covered & processed thru Pharmacy Benefit (PBM or Part D)

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE A9513 LUTATHERA LUTETIUM LU 177 11/11/2019 n/a A9543 ZEVALIN IBRITUMOMAB TIUXETAN 11/14/2016 n/a A9590 AZEDRA IODINE I-131 IOBENGUANE 11/11/2019 n/a ■ BlueCare HMO (Group & Individual plans) ■ My Blue* ■ BlueSelect (Group & Individual plans) ■ BlueOptions ACA/ CE Plans (Group & Individual plans) PADP Drug List ■ SimplyBlue

• Prior Authorization required in addition to referral when applicable Member Benefit Arrangements Require Prior Auth (all provider arrangements) NOTE: Member benefit arrangements that do not require prior authorization and/or provider contracts that do not align with Florida Blue Utilization Management Programs (PADP) are eligible for a Voluntary Predetermination of Select Services (VPSS) which for the PADP drug list will be reviewed by Prime Therapeutics Management MPS division (formerly known as: Magellan Rx Management MRxM/ ICORE). For the drugs that are not included in the PADP Drug list, the VPSS would be managed by Florida Blue.
  For the Member benefit and/or provider arrangements (UM) that require prior authorization for the listed drugs, a separate review is NOT required for the administration/ per diem services unless separately identified. When member product requires a referral to Specialist and/or prior authorization for Home Nursing services (i.e. My Blue, etc), these will be separately reviewed by Florida Blue through normal process.
  ■ BlueChoice Group ACA/ CE Plans Additions to the PADP Drug List will be made periodically in accordance with the applicable provisions of the contract(s). Member benefit agreements may require prior authorization which would include all the drugs included in the PADP List that will be managed by Magellan Rx Management as well as additional drugs that are not included in the PADP Drug List that will be managed by Florida Blue, The additional drugs that require prior authorization based upon the member's benefit agreement that are not included in PADP, can be located on the Medical and Specialty Drug UM List.
  Below are the member's benefit arrangements that would require prior authorizations regardless of the physician and providers participation:
  p g y p g ( y g g ICORE) since July 2009 with periodic drug updates for Florida physicians who buy and bill and administer the included drugs within the physician location. Florida Blue physician and providers that participate with Florida Blue Utilization Management Programs (PADP) are required to obtain a prior authorization for the drugs included in the PADP Drug list prior to the administration. If a prior authorization is not obtained for the applicable drug(s), payment for that service will be denied, and the Member cannot be held responsible for the denied charges.

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE A9600 METASTRON STRONTIUM SR-89 CHLORIDE 11/11/2019 n/a A9604 QUADRAMET SAMARIUM SM-153 LEXIDRONAM 11/11/2019 n/a A9606 XOFIGO RADIUM RA223 DICHLORIDE THER 11/14/2016 n/a A9607 PLUVICTO LUTETIUM (177LU) VIPIVOTIDE TETRAXETAN 03/23/2022 n/a A9699 UNCLASSIFIED RADIOPHARMACEUTICAL UNCLASSIFIED RADIOPHARMACEUTICAL* 11/11/2019 n/a J0013 SPRAVATO ESKETAMINE 03/01/2026 n/a J0129 ORENCIA IV ABATACEPT 01/01/2014 n/a J0172 ADUHELM ADUCANUMAB-AVWA 06/07/2021 n/a J0174 LEQEMBI LECANEMAB-IRMB 01/06/2023 n/a J0175 KISUNLA DONANEMAB-AZBT 07/02/2024 n/a J0177 EYLEA HD AFLIBERCEPT 08/18/2023 n/a J0178 EYLEA AFLIBERCEPT 04/01/2015 n/a J0179 BEOVU BROLUCIZUMAB-DBLL 11/11/2019 n/a J0180 FABRAZYME AGALSIDASE BETA 11/11/2019 n/a J0185 CINVANTI APREPITANT 11/11/2019 n/a J0202 LEMTRADA ALEMTUZUMAB 11/14/2016 n/a J0208 PEDMARK SODIUM THIOSULFATE 03/01/2026 n/a J0217 LAMZEDE VELMANASE ALFA-TYCV 04/13/2023 n/a J0218 XENPOZYME OLIPUDASE-ALFA 08/31/2022 n/a J0219 NEXVIAZYME AVALGLUCOSIDASE ALFA-NGPT 08/06/2021 n/a J0221 LUMIZYME ALGLUCOSIDASE ALFA 11/11/2019 n/a J0222 ONPATTRO PATISIRAN 11/11/2019 n/a J0223 GIVLAARI GIVOSIRAN 03/01/2026 n/a J0224 OXLUMO LUMASIRAN 03/01/2026 n/a J0225 AMVUTTRA VUTRISIRAN 03/01/2026 n/a J0256 ARALAST NP ALPHA 1-PROTEINASE INHIBITOR 01/01/2014 n/a J0256 ARALAST ALPHA 1-PROTEINASE INHIBITOR 01/01/2014 n/a J0256 PROLASTIN-C ALPHA 1-PROTEINASE INHIBITOR 01/01/2014 n/a J0256 ZEMAIRA ALPHA 1-PROTEINASE INHIBITOR 01/01/2014 n/a J0257 GLASSIA ALPHA 1-PROTEINASE INHIBITOR 01/01/2014 n/a J0364 APOKYN APOMORPHINE HYDROCHLORIDE 03/01/2026 n/a J0470 BAL IN OIL DIMERCAPROL 11/11/2019 n/a J0490 BENLYSTA IV BELIMUMAB IV 11/11/2019 n/a J0491 SAPHNELO ANIFROLUMAB-FNIA 07/30/2021 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J0517 FASENRA BENRALIZUMAB 11/11/2019 n/a J0565 ZINPLAVA BEZLOTOXUMAB 11/11/2019 n/a J0567 BRINEURA CERLIPONASE ALFA 11/11/2019 n/a J0570 PROBUPHINE IMPLANT BUPRENORPHINE IMPLANT 11/11/2019 n/a J0584 CRYSVITA BUROSUMAB-TWZA 11/11/2019 n/a J0585 BOTOX ONABOTULINUMTOXIN A 01/01/2014 n/a J0586 DYSPORT ONABOTULINUMTOXIN A 01/01/2014 n/a J0587 MYOBLOC ONABOTULINUMTOXIN B 01/01/2014 n/a J0588 XEOMIN ONABOTULINUMTOXIN A 01/01/2014 n/a J0589 DAXXIFY DAXIBOTULINUMTOXIN A-LANM 08/11/2023 n/a J0597 BERINERT C1 ESTERASE INHIBITOR 01/01/2014 n/a J0600 CALCIUM DISODIUM EDETATE CALCIUM DISODIUM 11/11/2019 n/a J0638 ILARIS CANAKINUMAB 11/14/2016 n/a J0641 FUSILEV LEVOLEUCOVORIN 04/01/2015 n/a J0642 KHAPZORY LEVOLEUCOVORIN 10/01/2019 n/a J0717 CIMZIA CERTOLIZUMAB PEGOL 01/01/2014 n/a J0738 YEZTUGO (inj) LENACAPAVIR (inj) 03/01/2026 n/a J0775 XIAFLEX COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM 11/11/2019 n/a J0791 ADAKVEO CRIZANLIZUMAB 11/20/2019 n/a J0799 HIV PRE-EXPOSURE NOC HIV PRE-EXPOSURE NOC* 03/01/2026 n/a J0870 RYTELO IRNETELSTAT 06/06/2024 n/a J0881
ARANESP DARBEPOETIN ALFA 07/20/2009 n/a J0885 EPOGEN EPOETIN ALFA 07/20/2009 n/a J0885 PROCRIT EPOETIN ALFA 07/20/2009 n/a J0888 MIRCERA EPOETIN BETA (non-ESRD use) 01/01/2015 n/a J0896 REBLOZYL LUSPATERCEPT-AAMT 11/11/2019 n/a J0897 PROLIA DENOSUMAB 01/01/2014 n/a J0897 XGEVA DENOSUMAB 01/01/2014 n/a J1201 QUZYTTIR CETIRIZINE HYDROCHLORIDE 03/01/2026 n/a J1203 POMBILITI CIPAGLUCOSIDASE ALFA-ATGA 09/28/2023 n/a J1246 UNITUXIN DINUTUXIMAB 05/01/2017 n/a J1290 KALBITOR ECALLANTIDE 01/01/2014 n/a J1299 SOLIRIS ECULIZUMAB 01/01/2014 n/a J1301 RADICAVA EDARAVONE 11/11/2019 n/a J1302 ENJAYMO SUTIMLIMAB-JOME 02/04/2022 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J1303 ULTOMIRIS RAVULIZUMAB-CWVZ 11/11/2019 n/a J1304 QALSODY TOFERSEN 03/01/2026 n/a J1305 EVKEEZA EVINACUMAB-DGNB 02/16/2021 n/a J1306 LEQVIO INCLISIRAN 03/01/2026 n/a J1307 PIASKY CROVALIMAB-AKKZ 06/20/2024 n/a J1322 VIMIZIM ELOSULFASE ALFA 11/11/2019 n/a J1323 ELREXFIO ELRANATAMAB-BCMM 08/14/2023 n/a J1325 FLOLAN EPOPROSTENOL 11/11/2019 n/a J1325 VELETRI EPOPROSTENOL 11/11/2019 n/a J1326 VYLOY ZOLBETUXIMAB-CLZB 10/18/2024 n/a J1426 AMONDYS 45 CASIMERSEN 03/01/2026 n/a J1427 VILTEPSO VILTOLARSEN 03/01/2026 n/a J1428 EXONDYS 51 ETEPLIRSEN 11/11/2019 n/a J1429 VYONDYS 53 GOLODIRSEN 03/01/2026 n/a J1434 FOCINVEZ FOSAPREPITANT 03/01/2026 n/a J1437 MONOFERRIC FERRIC DERISOMALTOSE 03/01/2026 n/a J1439 INJECTAFER FERRIC CARBOXYMALTOSE 11/11/2019 n/a J1440 REBYOTA FECAL MICROBIOTA, LIVE-JSLM 01/09/2023 n/a J1442 NEUPOGEN FILGRASTIM 07/20/2009 n/a J1447 GRANIX TBO-FILGRASTIM 01/01/2016 n/a J1448 COSELA TRILACICLIB 03/01/2026 n/a J1449 ROLVEDON EFLAPEGRASTIM-XNST 09/09/2022 n/a J1453 EMEND FOSAPREPITANT 11/14/2016 06/30/2021 J1454 AKYNZEO FOSNETUPITANT & PALONOSE 11/11/2019 n/a J1458 NAGLAZYME GALSULFASE 11/11/2019 n/a J1459 PRIVIGEN HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1552 ALYGLO HUMAN IMMUNE GLOBULIN 03/08/2024 n/a J1554 ASCENIV HUMAN IMMUNE GLOBULIN 10/01/2019 n/a J1556 BIVIGAM
HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1557 GAMMAPLEX HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1561 GAMMAKED HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1561 GAMUNEX HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1561 GAMUNEX-C HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1566 CARIMUNE NF HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1566 GAMMAGARD SD HUMAN IMMUNE GLOBULIN 01/16/2012 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J1566 PANGLOBULIN NF HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1568 OCTAGAM HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1569 GAMMAGARD LIQUID HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1572 FLEBOGAMMA HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1576 PANZYGA IMMUNE GLOBULIN IV 09/02/2019 n/a J1599 Unclassified IVIG HUMAN IMMUNE GLOBULIN 01/16/2012 n/a J1602 SIMPONI ARIA GOLIMUMAB 11/14/2016 n/a J1627 SUSTOL GRANISETRON, extended-release 11/11/2019 n/a J1628 TREMFYA IV GUSELKUMAB IV 09/11/2024 n/a J1726 MAKENA HYDROXYPROGESTERONE CAPROATE 11/14/2016 n/a J1729 HYDROXYPROGESTERONE CAPROATE HYDROXYPROGESTERONE CAPROATE 11/11/2019 n/a J1740 BONIVA IBANDRONATE SODIUM 11/14/2016 02/14/2021 J1743 ELAPRASE IDURSULFASE 11/11/2019 n/a J1745 REMICADE INFLIXIMAB 01/01/2014 n/a J1747 SPEVIGO SPESOLIMAB 09/01/2022 n/a J1786 CEREZYME IMUGLUCERASE 01/01/2014 n/a J1809 NULIBRY FOSDENOPTERIN 03/01/2026 n/a J1823 UPLIZNA INEBILIZUMAB-CDON 07/10/2020 n/a J1930 SOMATULINE DEPOT LANREOTIDE 11/14/2016 n/a J1931 ALDURAZYME LARONIDASE 11/11/2019 n/a J1932 CIPLA LANREOTIDE 10/01/2022 n/a J1950 LUPRON DEPOT LEUPROLIDE ACETATE 01/01/2014 n/a J1951 FENSOLVI LEUPROLIDE ACETATE 03/01/2026 n/a J1952 CAMCEVI LEUPROLIDE 01/01/2021 n/a J1954 LUTRATE LEUPROLIDE DEPOT 01/01/2023 n/a J2182 NUCALA MEPOLIZUMAB 11/11/2019 n/a J2267 OMVOH IV MIRIKIZUMAB-MRKZ IV 10/26/2023 n/a J2277 APHEXDA MOTIXAFORTIDE 03/01/2026 n/a J2323 TYSABRI NATALIZUMAB 04/01/2013 n/a J2326 SPINRAZA NUSINERSEN 03/01/2026 n/a J2327 SKYRIZI IV RISANKIZUMAB-RZAA 06/16/2022 n/a J2329 BRIUMVI UBLITUXIMAB 12/28/2022 n/a J2350 OCREVUS OCRELIZUMAB 11/11/2019 n/a J2351 OCREVUS ZUNOVO OCRELIZUMAB; HYALURONIDASE-OCSQ 09/13/2024 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J2353 SANDOSTATIN LAR DEPOT OCTREOTIDE 01/01/2014 n/a J2356 TEZSPIRE TEZEPELUMAB-EKKO 12/17/2021 n/a J2357 XOLAIR OMALIZUMAB 01/01/2014 n/a J2468 POSFREA PALONOSETRON HYDROCHLORIDE 03/01/2026 n/a J2469 ALOXI PALONOSETRON 07/20/2009 10/31/2021 J2502 SIGNIFOR LAR PASIREOTIDE , Long Acting 11/11/2019 n/a J2503 MACUGEN
PEGAPTANIB SODIUM 04/01/215 n/a J2506 NEULASTA PEGFILGRASTIM 07/20/2009 n/a J2507 KRYSTEXXA PEGLOTICASE 11/14/2016 n/a J2508 ELFABRIO PEGUNIGALSIDASE ALFA-IWXJ 05/09/2023 n/a J2562 MOZOBIL PLERIXAFOR 11/14/2016 n/a J2724 CEPROTIN PROTEIN C CONCENTRATE 11/11/2019 n/a J2777 VABYSMO FARICIMAB-SVOA 01/28/2022 n/a J2778 LUCENTIS RANIBIZUMAB 04/01/2015 n/a J2779 SUSVIMO RANOBIZUMAB 10/22/2021 n/a J2781 SYFOVRE PEGCETACOPLAN 03/01/2026 n/a J2782 IZERVAY AVACINCAPTAD PEGOL 03/01/2026 n/a J2783 ELITEK RASBURICASE 11/14/2016 n/a J2786 CINQAIR RESLIZUMAB 11/11/2019 n/a J2787 PHOTREXA VISCOUS RIBOFLAVIN 5'PHOSPHATE 11/11/2019 n/a J2796 NPLATE ROMIPLOSTIM New HCPCS, J2802 effective 01/01/2025 01/01/2014 n/a J2797 VARUBI ROLAPITANT 11/11/2019 n/a J2802 NPLATE ROMIPLOSTIM 01/01/2014 n/a J2820 LEUKINE SARGRAMOSTIM (GM-CSF) 11/14/2016 n/a J2840 KANUMA SEBELIPASE ALFA 11/11/2019 n/a J2860 SYLVANT SITUXIMAB 11/11/2019 n/a J2998 RYPLAZIM PLASMINOGEN, HUMAN-TVMH 06/04/2021 n/a J3032 VYEPTI EPTINEZUMAB-JJMR 02/21/2020 n/a J3055 TALVEY TALQUETAMAB-TGVS 08/09/2023 n/a J3060 ELELYSO TALIGLUCERASE ALFA 11/14/2016 n/a J3111 EVENITY ROMOSOZUMAB-AQQG 11/11/2019 n/a J3145 AVEED TESTOSTERONE UNDECANOATE 11/11/2019 n/a J3241 TEPEZZA TEPROTUMUMAB-TRBW 01/28/2020 n/a J3245 ILUMYA TILDRAKIZUMAB 11/11/2019 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J3247 COSENTYX IV EXAGAMGLOGENE AUTOTEMCEL IV 10/25/2023 n/a J3262 ACTEMRA TOCILIZUMAB 01/01/2014 n/a J3263 LOQTORZI TORIPALIMAB-TPZI 10/27/2023 n/a J3299 XIPERE TRIAMCINOLONE ACETONIDE 03/01/2026 n/a J3304 ZILRETTA TRIAMCINOLANE ACETONIDE 11/11/2019 n/a J3315 TRELSTAR DEPOT TRIPTORELIN PAMOATE 01/01/2014 n/a J3315 TRELSTAR LA TRIPTORELIN PAMOATE 01/01/2014 n/a J3316 TRIPTODUR TRIPTORELIN, EXTENDED-RELEASE 11/11/2019 n/a J3357 STELARA SQ USTEKINUMAB SQ 01/01/2014 n/a J3358 STELARA IV USTEKINUMAB IV 07/01/2017 n/a J3380 ENTYVIO VEDOLIZUMAB 01/01/2015 n/a J3385 VPRIV VELAGLUCERASE ALFA 01/01/2014 n/a J3396 VISUDYNE VERTEPORFIN 11/14/2016 n/a J3397 MEPSEVII VESTRONIDASE ALFA-VJBK 11/11/2019 n/a J3401 VYJUVEK BEREMAGENE GEPERPAVEC-SVDT 05/19/2023 n/a J3402 RYONCIL REMESTEMCEL-L-RKND 12/18/2024 n/a J3489 ZOMETA/ RECLAST ZOLEDRONIC ACID 01/01/2014 02/14/2021 J3590 UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS* 11/11/2019 n/a J7171 ADZYNMA ADAMTS13, RECOMBINANT-KRHN 11/09/2023 n/a J7311 RETISERT FLUOCINOLONE ACETONIDE, intravitreal implant 11/14/2016 n/a J7312 OZURDEX DEXAMETHASONE, intravitreal implant 11/14/2016 n/a J7313 ILUVIEN FLUCINOLONE ACETONIDE, intravitreal implant 11/14/2016 n/a J7314 YUTIQ FLUOCINOLONE ACETONIDE, intravitreal implant 11/11/2019 n/a J7318 DUROLANE HYALURONAN/ DERIVATIVE 11/11/2019 n/a J7320 GENVISC 850 HYALURONAN/ DERIVATIVE 11/14/2016 n/a J7321 HYALGAN SODIUM HYALURONATE 04/01/2013 n/a J7321 SUPARTZ SODIUM HYALURONATE 04/01/2013 n/a J7321 VISCO-3 SODIUM HYALURONATE 05/01/2017 n/a J7322 HYMOVIS HYALURONAN/ DERIVATIVE 01/01/2017 n/a J7323 EUFLEXXA SODIUM HYALURONATE 04/01/2013 n/a J7324 ORTHOVISC HIGH MOLECULAR WEIGHT HYALURONAN INJECTION 04/01/2013 n/a J7325 SYNVISC HYLAN G-F 20 04/01/2013 n/a J7325 SYNVISC ONE HYLAN G-F 20 04/01/2013 n/a J7326 GEL-ONE CROSS-LINKED HYALURONATE 04/01/2013 n/a J7327 MONOVISC HIGH MOLECULAR WEIGHT HYALURONAN 01/01/2015 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J7328 GEL-SYN HYALURONAN/ DERIVATIVE 01/01/2016 n/a J7329 TRIVISC HYALURONAN/ DERIVATIVE 11/11/2019 n/a J7331 SYNOJOYT SYNOJOYNE 11/11/2019 n/a J7332 TRILURON TRILURON 11/11/2019 n/a J7352 SCENESSE AFAMELANOTIDE 03/01/2026 n/a J7354 YCANTH CANTHARIDIN 03/01/2026 n/a J7355 IDOSE TR TRAVOPROST INTRACAMERAL 03/01/2026 n/a J7402 SINUVA IMPLANT MOMELASONE FUROATE SINUS IMPLANT 11/11/2019 n/a J9011 DATROWAY DATOPOTAMAB DERUXTECAN-DLNK 01/17/2025 n/a J9019 ERWINAZE ASPARAGINASE 11/14/2016 n/a J9021 RYLAZE ASPARAGINASE ERWINIA CHRYSANTHAMI (RECOMBINANT)- RYWN 06/30/2021 n/a J9022 TECENTRIQ ATEZOLIZUMAB 11/14/2016 n/a J9023 BAVENCIO AVELUMAB 03/23/2017 n/a J9024 TECENTRIQ HYBREZA ATEZOLIZUMAB & HYALURONIDASE-TQJS 09/12/2024 n/a J9025 VIDAZA AZACITIDINE 04/01/2015 n/a J9026 IMDELLTRA TARLATAMAB-DLLE 05/16/2024 n/a J9028 ANKTIVA NOGAPENDEKIN ALFA INBAKICEPT-PMLN 04/22/2024 n/a J9029 ADSTILADRIN NADOFARAGENE FIRADENOVEC-VNCG 12/16/2022 n/a J9032 BELEODAQ BELINOSTAT 11/14/2016 n/a J9033 TREANDA BENDAMUSTINE 04/01/2015 n/a J9034 BENDEKA BENDAMUSTINE 01/01/2017 n/a J9035 AVASTIN (oncology use) BEVACIZUMAB 07/20/2009 n/a J9036 BELRAPZO BENDAMUSTINE HCI 05/15/2018 n/a J9037 BLENREP BELANTAMAB MAFODOTIN-BLMF 08/20/2020 n/a J9038 NIKTIMVO AXATILIMAB-CSFR 08/14/2024 n/a J9039 BLINCYTO BLINATUMOMAB 11/14/2016 n/a J9041 VELCADE BORTEZOMIB 04/01/2013 08/15/2025 J9042 ADCETRIS BRENTUXIMAB VEDOTIN 11/14/2016 n/a J9043 JEVTANA CABAZITAXEL 01/01/2014 n/a J9044 BORTEZOMIB BORTEZOMIB New HCPCS J9046, J9048, & J9049 effective 01/01/2023 12/04/2017 12/31/2022 J9046 BORTEZOMIB BORTEZOMIB 01/01/2023 08/15/2025 J9047 KYPROLIS CARFILZOMIB 11/14/2016 n/a J9048 BORTEZOMIB BORTEZOMIB 01/01/2023 08/15/2025

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J9049 BORTEZOMIB BORTEZOMIB 01/01/2023 08/15/2025 J9054 BORUZU BORTEZOMIB 04/01/2025 n/a J9055 ERBITUX CETUXIMAB 04/01/2013 n/a J9056 VIVIMUSTA BENDAMUSTINE HYDROCHLORIDE 12/07/2022 n/a J9057 ALIQOPA COPANLISIB 09/18/2017 n/a J9058 BENDAMUSTINE BENDAMUSTINE 07/01/2023 n/a J9059 BENDAMUSTINE BENDAMUSTINE 07/01/2023 n/a J9061 RYBREVANT AMIVANTAMAB-VMJW 05/21/2021 n/a J9063 ELAHERE MIRVETUXIMAB SORAVTANSINE-GYNX 11/28/2022 n/a J9064 CABAZITAXEL CABAZITAXEL 10/01/2023 n/a J9118 ASPARLAS CALASPARGASE PAGOL-MKNL 10/01/2019 n/a J9119 LIBTAYO CEMIPLIMAB-RWIC 09/28/2018 n/a J9144 DARZALEX FASPRO DARATUMUMAB & HYALURONIDASE-FIHJ 05/11/2020 n/a J9145 DARZALEX DARALUMUMAB 11/14/2016 n/a J9153 VYXEOS DAUNORUBICIN and CYTARABINE 08/11/2017 n/a J9155 FIRMAGON DEGARELIX, 1MG 04/01/2013 12/31/2014 J9161 LYMPHIR DENILEUKIN DIFTITOX-CXDL 08/07/2024 n/a J9171 DOCEFREZ DOCETAXEL 04/01/2013 n/a J9171 TAXOTERE DOCETAXEL 04/01/2013 n/a J9172 DOCETAXEL DOCETAXEL 01/01/2024 n/a J9173 IMFINZI DURVALUMAB 05/01/2017 n/a J9174 BEIZRAY DOCETAXEL 07/01/2025 n/a J9176 EMPLICITI ELOTUZUMAB 11/14/2016 n/a J9177 PADCEV ENFORTUMAB VEDOTIN-EJFV 12/18/2019 n/a J9179 HALAVEN ERIBULIN 04/01/2013 n/a J9184 AVGEMSI GEMCITABINE 06/27/2025 n/a J9198 INFUGEM GEMCITABINE HYDROCHLORIDE 04/08/2019 n/a J9202 ZOLADEX GOSERELIN ACETATE 01/01/2014 n/a J9203 MYLOTARG GEMTUZUMAB OZOGAMICIN 09/07/2017 n/a J9204 POTELIGEO MOGAMULIZUMAB-KPKC 08/17/2018 n/a J9205 ONIVYDE IRINOTECAN LIPOSOME 11/14/2016 n/a J9207 IXEMPRA IXABEPILONE 03/01/2026 n/a J9210 GAMIFANT EMAPALUMAB-LZSG 11/11/2019 n/a J9217 ELIGARD LEUPROLIDE ACETATE 01/01/2014 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J9217 LUPRON DEPOT LEUPROLIDE ACETATE 01/01/2014 n/a J9218 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 03/01/2026 n/a J9223 ZEPZALCA LURBINECTEDIN 06/19/2020 n/a J9225 VANTAS HISTRELIN ACETTE 01/01/2014 n/a J9226 SUPPRELIN LA HISTRELIN ACETATE 04/01/2015 n/a J9227 SARCLISA ISATUXIMAB-IRFC 03/09/2020 n/a J9228 YERVOY IPILIMUMAB 04/01/2013 n/a J9229 BESPONSA INOTUZUMAB OZOGAMICIN 08/18/2017 n/a J9246 EVOMELA MELPHALAN HCI 03/01/2026 n/a J9247 PEPAXTO MELPHALAN FLUFENAMIDE 03/01/2021 n/a J9248 HEPZATO KIT MELPHALAN HYDROCHLORIDE 08/14/2023 n/a J9256 IMAAVY NIPOCALIMAB-AAHU 04/29/2025 n/a J9258 PACLITAXEL PACLITAXEL 01/01/2024 n/a J9259 PACLITAXEL PROTEIN-BOUND PACLITAXEL PROTEIN-BOUND 0701/2023 n/a J9261 ARRANON NELARABINE 03/01/2026 n/a J9262 SYNRIBO OMACETAXINE MEPESUCCINATE 11/14/2016 n/a J9263 ELOXATIN OXALIPLATIN 04/01/2013 06/14/2024 J9264 ABRAXANE PACLITAXEL 04/01/2013 n/a J9269 ELZONRIS TAGRAXOFUSP-ERZS 12/21/2018 n/a J9271 KEYTRUDA PEMBROLIZUMAB 11/14/2016 n/a J9272 JEMPERLI DOSTARLIMAB-GXLY 04/22/2021 n/a J9273 TIVDAK TISOTUMAB VEDOTIN-TFTV 09/20/2021 n/a J9274 KIMMTRAK TEBENTAFUSP-TEBN 01/25/2022 n/a J9275 UNLOXCYT COSIBELIMAB-IPDL 12/13/2024 n/a J9276 ZIIHERA ZANIDATAMAB-HRII 11/21/2024 n/a J9281 JELMYTO MITOMYCIN 04/16/2020 n/a J9282 ZUSDURI MITOMYCIN 06/12/2025 n/a J9285 LARTRUVO OLARATUMAB 03/06/2017 n/a J9286 COLUMVI GLOFITAMAB-GXBM 06/15/2023 n/a J9289 OPDIVO QVANTIG NIVOLUMAB AND HYALURONIDASE-NVHY 12/27/2025 n/a J9292 AXTLE PEMETREXED 01/01/2025 n/a J9294 PEMETREXED PEMETREXED 04/01/2023 n/a J9295 PORTRAZZA NECITUMUMAB 11/14/2016 n/a J9296 PEMETREXED PEMETREXED 04/01/2023 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J9297 PEMETREXED PEMETREXED 04/01/2023 n/a J9298 OPDUALAG NIVOLUMAB ELATLIMAB-RMBW 03/18/2022 n/a J9299 OPDIVO NIVOLUMAB 11/14/2016 n/a J9301 GAZYVA OBINUTUZUMAB 11/14/2016 n/a J9302 ARZERRA OFATUMUMAB 11/14/2016 n/a J9303 VECTIBIX PANITUMUMAB 04/01/2013 n/a J9304 PEMFEXY PEMETREXED 10/01/2020 n/a J9305 ALIMTA PEMETREXED 04/01/2013 n/a J9306 PERJETA PERTUZUMAB 11/14/2016 n/a J9307 FOLOTYN PRALATEXATE 11/14/2016 n/a J9308 CYRAMZA RAMUCIRUMAB 11/14/2016 n/a J9309 POLIVY POLATUZUMAB VEDOTIN-PIIQ 06/10/2019 n/a J9311 RITUXAN HYCELA RITUXIMAB-HYALURONIDASE 06/22/2017 n/a J9312 RITUXAN RITUXIMAB 04/01/2013 n/a J9313 LUMOXITI MOXETUMOMAB PASUDOTOX-TDFK 10/16/2018 n/a J9314 PEMETREXED PEMETREXED 01/01/2023 n/a J9316 PHESGO PERTUZUMAB, TRASTUZUMAB, and HYALURONIDASE-ZZXF 06/29/2020 n/a J9317 TRODELVY SACITUZUMAB GOVITECAN-HZIY 04/22/2020 n/a J9318 ROMIDEPSIN ROMIDEPSIN, non-lyophilied 03/13/2020 n/a J9319 ISTODAX ROMIDEPSIN, lyophilied 10/01/2021 n/a J9321 EPKINLY EPCORITAMAB-BYSP 05/19/2023 n/a J9322 PEMETREXED PEMETREXED 07/01/2023 n/a J9323 PEMETREXED PEMETREXED 07/01/2023 n/a J9324 PEMRYDI RTU PEMETREXED 01/01/2024 n/a J9325 IMLYGIC TALIMOGENE LAHERPAREPVEC 11/14/2016 n/a J9326 EMRELIS TELISOTUZUMAB VEDOTIN-TLLV 05/14/2025 n/a J9329 TEVIMBRA TISLELIZUMAB 03/13/2024 n/a J9330 TORISEL TEMSIROLIMUS 11/14/2016 n/a J9331 FYARRO SIROLIMUS ALBUMIN-BOUND NANOPARTICLES 11/22/2021 n/a J9332 VYVGART EFGARTIGIMOD ALFA-FCAB 12/27/2021 n/a J9333 RYSTIGGO ROZANOLIXIZUMAB-NOLI 06/28/2023 n/a J9334 VYVGART HYTRULO EFGARTIGIMOD ALFA-FCAB 06/20/2023 n/a J9341 TEPYLUTE THIOTEPA 06/24/2024 n/a J9345 ZYNYZ RETIFANLIMAB-DLWR 03/22/2023 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J9347 IMJUDO TREMELIMUMAB-ACTL 10/21/2022 n/a J9348 DANYELZA NAXITAMAB-GQGK 11/25/2020 n/a J9349 MONJUVI TAFASITAMAB-CXIX 08/03/2020 n/a J9350 LUNSUMIO MOSUNETUZUMAB-AXGB 12/22/2022 n/a J9352 YONDELIS TRABECTEDIN 11/14/2016 n/a J9353 MARGENZA MARGETUXIMAB-CMKB 12/16/2020 n/a J9354 KADCYLA
ADO-TRASTUZUMAB 01/01/2014 n/a J9355 HERCEPTIN TRASTUZUMAB 07/20/2009 n/a J9356 HERCEPTIN HYLECTA TRASTUZUMAB HYALURONIDASE-OYSK 04/08/2019 n/a J9358 ENHERTU FAM-TRASTUZUMAB DERUXTECAN-NXKI 12/20/2019 n/a J9359 ZYNLONTA LONCASTUXIMAB TESIRINE-LPYL 04/23/2021 n/a J9361 RYZNEUTA EFBEMALENOGRASTIM ALFA-VUXW 11/16/2023 n/a J9376 VEOPOZ POZELIMAB-BBFG 08/18/2023 n/a J9380 TECVAYLI TECLISTAMAB-CQYV 10/25/2022 n/a J9381 TZIELD TEPLIZUMAB-MZWV 11/17/2022 n/a J9382 BIZENGRI ZENOCUTUZUMAB-ZBCO 12/04/2025 n/a J9400 ZALTRAP ZIV-AFLIBERCEPT 11/14/2016 n/a J9999 NOC NOC ANTINEOPLASTIC* 11/14/2016 n/a Q2043 PROVENGE SIPULEUCEL-T AUTOLOGOUS CD54+ CELLS 04/01/2013 n/a Q2049 LIPODOX DOXORUBICIN LIPOSOMAL 04/01/2015 n/a Q2050 DOXIL DOXORUBICIN LIPOSOMAL 04/01/2015 n/a Q5098 IMULDOSA USTEKINUMAB-SRLF 10/10/2024 n/a Q5099 STEQEYMA USTEKINUMAB-STBA 12/17/2024 n/a Q5100 YESINTEK USTEKINUMAB-KFCE 11/29/2024 n/a Q5101 ZARXIO FILGRASTIM-SNDZ 07/01/2015 n/a Q5103 INFLECTRA INFLIXIMAB-DYYB, BIOSIMILAR 07/01/2016 n/a Q5104 RENFLEXIS INFLIXIMAB-ABDA, BIOSIMILAR 07/25/2017 n/a Q5106 RETACRIT EPOESTIN ALFA-EPBX 10/01/2018 n/a Q5107 MVASI BEVACIZUMAB-AWWB 09/14/2017 n/a Q5108 FULPHILA PEGFILGRASTIM-JMDB 10/01/2018 n/a Q5109 IXIFI INFLIXIMAB-QBTX 01/01/2019 n/a Q5110 NIVESTYM FILGRASTIM-AAFI 01/01/2019 n/a Q5111 UDENYCA PEGFILGRASTIM-CBQV 03/01/2019 n/a Q5111 UDENYCA ONBODY PEGFILGRASTIM-CBQV ONBODY 01/23/2024 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE Q5112 ONTRUZANT TRASTUZUMAB-DTTB 07/01/2019 n/a Q5113 HERZUMA TRASTUZUMAB-PKRB 07/01/2019 n/a Q5114 OGIVRI TRASTUZUMAB-DKST 12/01/2017 n/a Q5115 TRUXIMA RITUXIMAB-ABBS 07/01/2019 n/a Q5116 TRAZIMERA TRAZIMERA 10/01/2019 n/a Q5117 KANJINTI TRASTUZUMAB-ANNS 07/22/2019 n/a Q5118 ZIRABEV ZIRABEV 10/01/2019 n/a Q5119 RUXIENCE RITUXIMAB-PVVR 07/23/2019 n/a Q5120 ZIEXTENZO PEGFILGRASTIM-BMEZ 11/11/2019 n/a Q5121 AVSOLA INFLIXIMAB-AXXQ 12/06/2019 n/a Q5122 NYVEPRIA PEGFILGRASTIM-APGF 06/10/2020 n/a Q5123 RIABNI RITUXIMAB-ARRX 12/17/2020 n/a Q5124 BYOOVIZ RANIBIZUMAB-NUNA 09/20/2021 n/a Q5125 RELEUKO FILGRASTIM-AYOW 02/25/2022 n/a Q5126 ALYMSYS BEVACIZUMAB-MALY 04/13/2022 n/a Q5127 STIMUFEND PEGFILGRASTIM-FPGK 09/01/2022 n/a Q5128 CIMERLI RANIBIZUMAB-EQRN 08/02/2022 n/a Q5129 VEGZELMA BEVACIZUMAB-ADCD 09/27/2022 n/a Q5130 FYLNETRA PEGFILGRASTIM-PBBK 05/26/2022 n/a Q5133 TOFIDENCE TOCILIZUMAB-BAVI 09/29/2023 n/a Q5134 TYRUKO NATALIZUMAB-SZTN 08/24/2023 n/a Q5135 TYENNE TOCILIZUMAB-AAZG 03/05/2024 n/a Q5136 JUBBONTI DENOSUMAB-BBDZ 10/01/2024 n/a Q5136 WYOST DENOSUMAB-BBDZ 10/01/2024 n/a Q5137 WEZLANA SQ USTEKINUMAB-AUUB SQ 10/31/2023 n/a Q5138 WEZLANA IV USTEKINUMAB-AUUB IV 10/31/2023 n/a Q5139 BKEMV ECULIZUMAB-AEEB New HCPCS, Q5152 effective 04/01/2025 05/28/2024 n/a Q5146 HERCESSI TRASTUZUMAB-STRF 04/25/2024 n/a Q5147 PAVBLU AFLIBERCEPT-AYYH 08/23/2024 n/a Q5148 NYPOZI FILGRASTIM-TXID 06/28/2024 n/a Q5149 ENZEEVU AFLIBERCEPT-ABZV 08/09/2024 n/a Q5150 AHZANTIVE AFLIBERCEPT-MRBB 06/28/2024 n/a Q5151 EPYSQLI ECULIZUMAB-AAGH 07/19/2024 n/a Q5152 BKEMV ECULIZUMAB-AEEB 05/28/2024 n/a Q5153 OPUVIZ AFLIBERCEPT-YSZY 05/20/2024 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE Q5154 OMLYCLO OMALIZUMAB-IGEC 03/07/2025 n/a Q5155 YESAFILI AFLIBERCEPT-JBVF 10/01/2025 n/a Q5156 AVTOZMA IV TOCILIZUMAB-ANOH IV 01/30/2025 n/a Q5157 OSENVELT DENOSUMAB-BMWO 02/28/2025 n/a Q5157 STOBOCLO DENOSUMAB-BMWO 02/28/2025 n/a Q5158 BOMYNTRA DENOSUMAB-BNHT 03/25/2025 n/a Q5158 CONEXXENCE DENOSUMAB-BNHT 03/25/2025 n/a Q5159 OSPOMYV DENOSUMAB-DSSB 02/13/2025 n/a Q5159 XBRYK DENOSUMAB-DSSB 02/13/2025 n/a Q5160 JOBEVNE BEVACIZUMAB-NWGD 04/09/2025 n/a Q9991 SUBLOCADE BUPRENORPHINE EXTENDED-RELEASE, 100MG OR LESS 11/11/2019 n/a Q9992 SUBLOCADE BUPRENORPHINE EXTENDED-RELEASE, GREATER 100MG 11/11/2019 n/a Q9996 PYZCHIVA SQ USTEKINUMAB-TTWE SQ 06/28/2024 n/a Q9997 PYZCHIVA IV USTEKINUMAB-TTWE IV 06/28/2024 n/a Q9998 SELARSDI USTEKINUMAB-AEKN 04/16/2024 n/a Q9999 OTULFI USTEKINUMAB-AAUZ 09/27/2024 n/a HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J9999 LUNSUMIO VELO MOSUNETUZUMAB-AXGB 12/19/2025 n/a J9999 RYBREVANT FASPRO AMIVANTAMAB and HYALURONIDASE-LPUJ 12/17/2025 n/a J3590 EXDENSUR DEPEMOKIMAB-ULAA 12/16/2025 n/a J3590 ARMLUPEG PEGFILGRASTIM 11/28/2025 n/a J9999 CLIGAVYX FULVESTRANT 11/21/2025 n/a J3590 JUBEREQ DENOSUMAB-DESU 11/20/2025 n/a J3590 OSVYRTI DENOSUMAB-DESU 11/20/2025 n/a J9999 POHERDY PERTUZUMAB-DPZB 11/13/2025 n/a J9999 BLENREP BELANTAMAB MAFODOTIN-BLMF 10/23/2025 n/a J3590 EYDENZELT AFLIBERCEPT-BOAV 10/02/2025 n/a J3590 EYDENZELT AFLIBERCEPT-BOAV* 10/02/2025 n/a PADP Unclassified HCPCS Drug List

• Includes existing and new to market physician administered drugs that are aligned with NOC A9699, J1599, J3590 & J9999. Once drug is assigned to HCPCS, the new HCPCS will be included in the PADP Drug List ** New HCPCS assigned by CMS. Drug was included in PADP prior to new HCPCS effective date

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J3590 ENOBY DENOSUMAB-QBDE 09/26/2025 n/a J1599 QIVIGY IMMUNE GLOBULIN IV 09/26/2025 n/a J3590 XTRENBO DENOSUMAB-QBDE 09/26/2025 n/a J9999 KEYTRUDA QLEX PEMBROLIZUMAB & BERAHYALURONIDASE ALFA-PMPH 09/19/2025 n/a J3590 AUKELSO DENOSUMAB-KYQQ 09/16/2025 n/a J3590 BOSAYA DENOSUMAB-KYQQ 09/16/2025 n/a J9999 INLEXZO GEMCITABINE 09/09/2025 n/a J3590 BILDYOS DENOSUMAB-NXXP 08/29/2025 n/a J3590 BILPREVDA DENOSUMAB-NXXP 08/29/2025 n/a J3590 PAPZIMEOS ZOPAPOGENE IMADENOVEC-DRBA 08/14/2025 n/a J9999/ C9308 KYXATA CARBOPLATIN 08/08/2025 n/a J9999 BENDAMUSTINE HYDROCHLORIDE BENDAMUSTINE HYDROCHLORIDE 07/03/2025 n/a J9999/ C9307 LYNOZYFIC LINVOSELTAMAB-GCPT 07/02/2025 n/a J3590 STARJEMZA USTEKINUMAB-HMNY 05/22/2025 n/a J3590 USTEKINUMAB-STBA USTEKINUMAB-STBA 04/28/2025 n/a J9999 PENPULIMAB-KCQX PENPULIMAB-KCQX 04/23/2025 n/a J9999 TRABECTEDIN TRABECTEDIN 04/09/2025 n/a J9999 GRAFAPEX TREOSULFAN 01/22/2025 n/a J1599 YIMMUGO IMMUNE GLOBULIN IV 06/13/2024 n/a J3590 YESAFILI AFLIBERCEPT-JBVF 05/20/2024 n/a J3590 WINREVAIR SOTATERCEPT-CSRK 03/26/2024 n/a J9999 AVZIVI BEVACIZUMAB-TNJN 12/06/2023 n/a J3590/ C9167 ADZYNMA ADAMTS13, RECOMBINANT-KRHN 11/09/2023 n/a J3590 REVCOVI ELAPEGADEMASE-IVLR 11/11/2019 n/a J9999 AVGEMSI GEMCITABINE New HCPCS, J9184 effective 01/01/2026 06/27/2025 n/a J3590/ C9305 IMAAVY NIPOCALIMAB-AAHU New HCPCS, J9256 effective 01/01/2026 04/29/2025 n/a J9999 ZUSDURI MITOMYCIN New HCPCS, J9282 effective 01/01/2026 06/12/2025 n/a J9999/ C9306 EMRELIS TELISOTUZUMAB VEDOTIN-TLLV New HCPCS, J9326 effective 01/01/2026 05/14/2025 n/a J9999 JOBEVNE BEVACIZUMAB-NWGD* New HCPCS, Q5160 effective 01/01/2026 04/09/2025 n/a

HCPCS/ CPT DRUG NAME GENERIC/ HCPCS DESCRIPTION PADP EFF DATE TERM DATE J3590 RYONCIL REMESTEMCEL-L-RKND New HCPCS, J3402 effective 10/01/2025 12/18/2024 n/a J9999/ C9174 DATROWAY DATOPOTAMAB DERUXTECAN-DLNK New HCPCS, J9011 effective 10/01/2025 01/17/2025 n/a J3590 OMLYCLO OMALIZUMAB-IGEC New HCPCS, Q5154 effective 10/01/2025 03/07/2025 n/a J3590 AVTOZMA IV TOCILIZUMAB-ANOH IV New HCPCS, Q5156 effective 10/01/2025 01/30/2025 n/a J3590 OSENVELT DENOSUMAB-BMWO New HCPCS, Q5157 effective 10/01/2025 02/28/2025 n/a J3590 STOBOCLO DENOSUMAB-BMWO New HCPCS, Q5157 effective 10/01/2025 02/28/2025 n/a J3590 BOMYNTRA DENOSUMAB-BNHT New HCPCS, Q5158 effective 10/01/2025 03/25/2025 n/a J3590 CONEXXENCE DENOSUMAB-BNHT New HCPCS, Q5158 effective 10/01/2025 03/25/2025 n/a J3590 OSPOMYV DENOSUMAB-DSSB New HCPCS, Q5159 effective 10/01/2025 02/13/2025 n/a J3590 XBRYK DENOSUMAB-DSSB New HCPCS, Q5159 effective 10/01/2025 02/13/2025 n/a ** C-Codes are only billable for the specified drug services within Hospital Outpatient setting. All other setting must be billed with the corresponding unspecified drug HCPCS until a listed HCPCS is assigned by CMS.

• Once drug is assigned to HCPCS, the new HCPCS will be included in the PADP Drug List and managed through Magellan Rx Management (MRxM). NOTE - Drugs associated to J9999, are NOT accepted with C9399. MRxM authorizations will not be applied when billing C9399.