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

NYS DOH - Never Pay Procedures Under APG Reimbursement

Effective January 1, 2020 - March 31, 2021
Px Code Procedure (Px) Description Alternative Payment Available* Date added to Never Pay List PX Codes End Dated
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  
J7180 Factor xiii anti-hem factor Yes 01/01/21  
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  
J7203 Factor ix recomb gly rebinyn Yes 01/01/21  
J7204 Inj recombin esperoct per iu Yes 01/01/21  
J7205 Factor viii fc fusion recomb Yes 01/01/18  
J7207 Factor viii pegylated recomb Yes 01/01/18  
J7208 Inj. jivi 1 iu Yes 01/01/21  
J7209 Factor viii nuwiq recomb 1iu Yes 01/01/18  
J7210 Inj, afstyla, 1 i.u. Yes 01/01/21  
J7211 Inj, kovaltry, 1 i.u. Yes 01/01/21  
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  
J9022 Inj, atezolizumab,10 mg Yes 01/01/21  
J9023 Injection, avelumab, 10 mg Yes 01/01/21  
J9027 Clofarabine injection Yes 12/01/08  
J9032 Injection, belinostat, 10mg Yes 01/01/21  
J9033 Injection, bendamustine hcl, 1 mg Yes 01/01/11  
J9034 Inj., bendeka 1 mg Yes 01/01/21  
J9035 Injection, bevacizumab, 10 mg Yes 01/01/11  
J9036 Inj. belrapzo/bendamustine Yes 01/01/21  
J9039 Injection, blinatumomab Yes 01/01/18  
J9042 Brentuximab vedotin inj Yes 01/01/21  
J9043 Cabazitaxel injection Yes 01/01/21  
J9044 Inj, bortezomib, nos, 0.1 mg Yes 01/01/21  
J9047 Injection, carfilzomib, 1 mg Yes 01/01/21  
J9050 Carmustine injection Yes 01/01/21  
J9055 Injection, cetuximab, 10 mg Yes 01/01/11  
J9057 Inj., copanlisib, 1 mg Yes 01/01/21  
J9098 Injection, cytarabine liposome, 10 mg Yes 01/01/11  
J9118 Inj. Calaspargase pegol-mknl Yes 01/01/21  
J9119 Inj., cemiplimab-rwlc, 1 mg Yes 01/01/21  
J9120 Injection, dactinomycin, 0.5 mg Yes 01/01/11  
J9145 Injection, daratumumab 10 mg Yes 01/01/21  
J9153 Inj daunorubicin, cytarabine Yes 01/01/21  
J9160 Injection, denileukin diftitox, 300 micrograms Yes 01/01/11  
J9173 Inj., durvalumab, 10 mg Yes 01/01/21  
J9176 Injection, elotuzumab, 1mg Yes 01/01/21  
J9177 Inj enfort vedo-ejfv 0.25mg Yes 01/01/21  
J9202 Goserelin acetate implant Yes 01/01/18  
J9203 Gemtuzumab ozogamicin 0.1 mg Yes 01/01/21  
J9204 Inj mogamulizumab-kpkc, 1 mg Yes 01/01/21  
J9205 Inj irinotecan liposome 1 mg Yes 01/01/21  
J9207 Injection, ixabepilone, 1 mg Yes 01/01/11  
J9210 Inj., emapalumab-lzsg, 1 mg Yes 01/01/21  
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  
J9227 Inj. isatuximab-irfc 10 mg Yes 01/01/21  
J9228 Ipilimumab injection Yes 01/01/21  
J9229 Inj inotuzumab ozogam 0.1 mg Yes 01/01/21  
J9245 Injection, melphalan hydrochloride, 50 mg Yes 01/01/11  
J9246 Inj., evomela, 1 mg Yes 01/01/21  
J9261 Nelarabine injection Yes 01/01/21  
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  
J9269 Inj. tagraxofusp-erzs 10 mcg Yes 01/01/21  
J9271 Inj pembrolizumab Yes 01/01/18  
J9285 Inj, olaratumab, 10 mg Yes 01/01/21  
J9295 Injection, necitumumab, 1 mg Yes 01/01/21  
J9299 Injection, nivolumab Yes 01/01/18  
J9301 Obinutuzumab inj Yes 01/01/18  
J9302 Ofatumumab injection Yes 01/01/21  
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  
J9309 Inj, polatuzumab vedotin 1mg Yes 01/01/21  
J9311 Inj rituximab, hyaluronidase Yes 01/01/21  
J9312 Inj., rituximab, 10 mg Yes 01/01/21  
J9313 Inj., lumoxiti, 0.01 mg Yes 01/01/21  
J9325 Inj talimogene laherparepvec Yes 01/01/21  
J9328 Temozolomide injection Yes 01/01/21  
J9352 Injection trabectedin 0.1mg Yes 01/01/21  
J9354 Inj, ado-trastuzumab emt 1mg Yes 01/01/18  
J9355 Injection, trastuzumab, 10 mg Yes 01/01/11  
J9356 Inj. herceptin hylecta, 10mg Yes 01/01/21  
J9357 Valrubicin injection Yes 01/01/21  
J9358 Inj fam-trastu deru-nxki 1mg Yes 01/01/21  
J9371 Inj, vincristine sul lip 1mg Yes 01/01/21  
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, 2020 - March 31, 2021
APG APG Desc Procedure Code Alternative Payment Available* Date added to Never Pay List PX Codes End Dated
430 Class I Chemotherapy Drugs   Yes - carve out 12/1/2008  
Leucovorin calcium injection J0640      
Epoprostenol injection J1325      
Gonadorelin hydroch/ 100 mcg J1620      
Sirolimus, oral J7520      
Oral everolimus J7527      
Capecitabine, oral, 150 mg J8520      
Capecitabine, oral, 500 mg J8521      
Cyclophosphamide oral 25 mg J8530      
Melphalan oral 2 mg J8600      
Temozolomide J8700      
Oral prescription drug chemo J8999      
Doxorubicin hcl injection J9000      
Carboplatin injection J9045      
Cisplatin 10 mg injection J9060      
Dacarbazine 100 mg inj J9130      
Inj, epirubicin hcl, 2 mg J9178      
Etoposide injection J9181      
Irinotecan injection J9206      
Mesna injection J9209      
Interferon alfa-n3 inj J9215      
Leuprolide acetate injeciton J9218      
Paclitaxel injection J9267      
Topotecan injection J9351      
Vinblastine sulfate inj J9360      
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  
Sincalide injection J2805      
Azathioprine parenteral J7501      
Oral aprepitant J8501      
Etoposide oral 50 mg J8560      
Rolapitant, oral, 1mg J8670      
Bcg live intravesical 1mg J9030      
Bleomycin sulfate injection J9040      
Fludarabine phosphate inj J9185      
Floxuridine injection J9200      
Ifosfamide injection J9208      
Idarubicin hcl injection J9211      
432     Yes - carve out 12/1/2008  
Inj levoleucovorin nos 0.5mg J0641      
Ceftaroline fosamil inj J0712      
Ibutilide fumarate injection J1742      
Interferon beta-1a inj J1826      
Palonosetron hcl J2469      
Pentastarch 10% solution J2513      
Asparaginase, nos J9020      
Azacitidine injection J9025      
Cyclophosphamide 100 mg inj J9070      
Daunorubicin citrate inj J9151      
Docetaxel injection J9171      
Mechlorethamine hcl inj J9230      
Mitoxantrone hydrochl / 5 mg J9293      
Flutamide 125 mg S0175      
433     Yes - carve out 12/1/2008  
Daptomycin injection J0878      
Quinupristin/dalfopristin J2770      
Oral netupitant, palonosetro J8655      
Inj cladribine per 1 mg J9065      
Daunorubicin injection J9150      
Degarelix injection J9155      
Inj. infugem, 100 mg J9198      
Injection, infugem, 200 mg J9199     7/1/2020
Streptozocin injection J9320      
Thiotepa injection J9340      
434     Yes - carve out 12/1/2008  
Cidofovir injection J0740      
Corticorelin ovine triflutal J0795      
Decitabine injection J0894      
Eptifibatide injection J1327      
Lepirudin J1945      
Tirofiban hcl J3246      
Treprostinil, non-comp unit J7686      
Gefitinib oral J8565      
Arsenic trioxide injection J9017      
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      
Imatinib 100 mg S0088      
Lomustine 10 mg S0178      
441     Yes - carve out 1/1/2010  
Amifostine J0207      
Dexrazoxane hcl injection J1190      
Leuprolide acetate /3.75 mg J1950      
Triptorelin pamoate J3315      
Inj., velcade 0.1 mg J9041      
Interferon alfa-2b inj J9214      
Mitomycin injection J9280      
443     Yes - carve out 1/1/2011  
Adalimumab injection J0135      
Denosumab injection J0897      
Pegademase bovine, 25 iu J2504      
Monoclonal antibodies J7505      
Aldesleukin injection J9015      
Sacituzumab govitecan-hziy J9317   1/1/2021  
Temsirolimus injection J9330      
Injection, fulvestrant J9395      
Sermorelin acetate injection Q0515      
465     Yes - carve out 7/1/2011  
Botulism ig iv 90288      
Inj, coagulation factor xa C9041     7/1/2020
Injection, caplacizumab-yhdp C9047      
Injection, givosiran C9056     7/1/2020
Injection, teprotumumab-trbw C9061     10/1/2020
Mitomycin pyelocalyceal inst C9064     1/1/2021
Injection, viltolarsen C9071   1/1/2021  
Injection, glucarpidase C9293      
Injection, alemtuzumab J0202      
Alglucosidase alfa injection J0220      
Lumizyme injection J0221      
Inj., patisiran, 0.1 mg J0222      
Inj givosiran 0.5 mg J0223      
Inj., cerliponase alfa 1 mg J0567      
Injection, burosumab-twza 1m J0584      
Inj., lanadelumab-flyo, 1 mg J0593      
Eculizumab injection J1300      
Inj., ravulizumab-cwvz 10 mg J1303      
Elosulfase alfa, injection J1322      
Inj, eteplirsen, 10 mg J1428      
Inj golodirsen 10 mg J1429      
Galsulfase injection J1458      
Inj. inebilizumab-cdon, 1 mg J1823   1/1/2021  
Inj, nusinersen, 0.1mg J2326      
Injection, ocrelizumab, 1 mg J2350      
Inj sebelipase alfa 1 mg J2840      
Inj. teprotumumab-trbw 10 mg J3241      
Inj., triptorelin xr 3.75 mg J3316      
Inj., vestronidase alfa-vjbk J3397      
Inj luxturna 1 billion vec g J3398      
Inj onase abepar-xioi treat J3399      
Inj andexxa, 10 mg J7169      
Inj., emicizumab-kxwh 0.5 mg J7170      
Inj, factor x, (human), 1iu J7175      
Factor xiii anti-hem factor J7180      
Factor xiii recomb a-subunit J7181      
Ganciclovir long act implant J7310      
Fluocinolone acetonide implt J7311      
Afamelanotide implant, 1 mg J7352   1/1/2021  
Inj., emapalumab-lzsg, 1 mg J9210      
Supprelin la implant J9226      
Ipilimumab injection J9228      
Inj. tagraxofusp-erzs 10 mcg J9269      
Mitomycin instillation J9281   1/1/2021  
Sipuleucel-t auto cd54+ Q2043      
495     Yes - carve out 7/1/2012  
Oral busulfan J8510      
Cabergoline, oral 0.25mg J8515      
Oral dexamethasone J8540      
Methotrexate oral 2.5 mg J8610      
Nabilone oral J8650      
Cytarabine hcl 100 mg inj J9100      
Fluorouracil injection J9190      
Interferon alfacon-1 inj J9212      
Methotrexate sodium inj J9250      
Methotrexate sodium inj J9260      
Vincristine sulfate 1 mg inj J9370      

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