Institutional Cost Report (ICR) Drug Carve Out List by Year
- 2020 ICR (XLSX)
Carve Out Drugs - List 1 (Px)
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.
Carve Out Drugs - List 2 (APG)
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.