Institutional Cost Report (ICR) Drug Carve Out List by Year
- 2021 ICR (XLSX)
Carve Out Drugs - List 1 (Px)
NYS DOH - Never Pay Procedures Under APG Reimbursement
Effective January 1, 2021 - March 31, 2022
| Px Code | Procedure (Px) Description | Alternative Payment Available* | Date added to Never Pay List | Date Removed from Never Pay List | PX Codes End Dated |
|---|---|---|---|---|---|
| J0207 | Amifostine | Yes | 07/01/21 | ||
| 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 | ||
| J0894 | Decitabine injection | Yes | 01/01/22 | ||
| J1322 | Elosulfase alfa, injection | Yes | 01/01/22 | ||
| 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 | ||
| J1950 | Leuprolide acetate /3.75 mg | Yes | 01/01/22 | ||
| 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 | ||
| J2506 | Inj pegfilgrast ex bio 0.5mg | Yes | 01/01/22 | ||
| J2562 | Injection, plerixafor, 1 mg | Yes | 01/01/11 | ||
| J2783 | Rasburicase | Yes | 01/01/21 | ||
| 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 | ||
| J3316 | Inj., triptorelin xr 3.75 mg | Yes | 01/01/22 | ||
| 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 | ||
| J7294 | Seg acet and eth estr yearly | Yes | 01/01/22 | ||
| J7295 | Eth estr and eton monthly | Yes | 01/01/22 | ||
| 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 | ||
| J7311 | Inj., retisert, 0.01 mg | Yes | 07/01/21 | ||
| 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 | ||
| J9061 | Inj, amivantamab-vmjw | Yes | 01/01/22 | ||
| 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 | ||
| J9272 | Inj, dostarlimab-gxly, 10 mg | Yes | 01/01/22 | ||
| J9280 | Mitomycin injection | Yes | 07/01/21 | ||
| 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 |
*APGs 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 | ||||
| Oral everolimus | J7527 | ||||
| Cyclophosphamide oral 25 mg | J8530 | ||||
| Melphalan oral 2 mg | J8600 | ||||
| Oral prescription drug chemo | J8999 | ||||
| Doxorubicin hcl injection | J9000 | ||||
| Bleomycin sulfate injection | J9040 | ||||
| Carboplatin injection | J9045 | ||||
| Dacarbazine 100 mg inj | J9130 | ||||
| Inj, epirubicin hcl, 2 mg | J9178 | ||||
| Fludarabine phosphate inj | J9185 | ||||
| Floxuridine injection | J9200 | ||||
| Irinotecan injection | J9206 | ||||
| Ifosfamide injection | J9208 | ||||
| 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 | ||
| Inj levoleucovorin nos 0.5mg | J0641 | ||||
| Eptifibatide injection | J1327 | ||||
| Tirofiban hcl | J3246 | ||||
| Etoposide oral 50 mg | J8560 | ||||
| Azacitidine injection | J9025 | ||||
| Bcg live intravesical 1mg | J9030 | ||||
| Docetaxel injection | J9171 | ||||
| Idarubicin hcl injection | J9211 | ||||
| 432 | Yes - carve out | 12/1/2008 | |||
| Inj cyclophosphamd auromedic | C9087 | 1/1/2022 | |||
| Decitabine injection | J0894 | ||||
| Pentastarch 10% solution | J2513 | ||||
| Arsenic trioxide injection | J9017 | ||||
| Asparaginase, nos | J9020 | ||||
| Inj cladribine per 1 mg | J9065 | ||||
| Cyclophosphamide 100 mg inj | J9070 | ||||
| Daunorubicin citrate inj | J9151 | ||||
| Mechlorethamine hcl inj | J9230 | ||||
| Mitoxantrone hydrochl / 5 mg | J9293 | ||||
| Flutamide 125 mg | S0175 | ||||
| 433 | Yes - carve out | 12/1/2008 | |||
| Busulfan injection | J0594 | 7/1/2021 | |||
| Daunorubicin injection | J9150 | ||||
| Degarelix injection | J9155 | ||||
| Inj. infugem, 100 mg | J9198 | ||||
| Injection, infugem, 200 mg | J9199 | 7/1/2020 | |||
| Mitomycin injection | J9280 | ||||
| Streptozocin injection | J9320 | ||||
| Thiotepa injection | J9340 | ||||
| Injection, fulvestrant | J9395 | ||||
| 434 | Yes - carve out | 12/1/2008 | |||
| Cidofovir injection | J0740 | ||||
| Leuprolide inj, camcevi, 1mg | J1952 | 1/1/2022 | |||
| Treprostinil, non-comp unit | J7686 | ||||
| Gefitinib oral | J8565 | ||||
| Interferon alfa-2a inj | J9213 | ||||
| Interferon gamma 1-b inj | J9216 | ||||
| Leuprolide acetate suspnsion | J9217 | ||||
| Plicamycin (mithramycin) inj | J9270 | ||||
| Imatinib 100 mg | S0088 | ||||
| Lomustine 10 mg | S0178 | ||||
| 441 | Yes - carve out | 1/1/2010 | |||
| Dexrazoxane hcl injection | J1190 | ||||
| Triptorelin pamoate | J3315 | ||||
| Clofarabine injection | J9027 | 7/1/2021 | |||
| Inj., velcade 0.1 mg | J9041 | ||||
| Temsirolimus injection | J9330 | ||||
| 443 | Yes - carve out | 1/1/2011 | |||
| Adalimumab injection | J0135 | ||||
| Denosumab injection | J0897 | ||||
| Monoclonal antibodies | J7505 | ||||
| Aldesleukin injection | J9015 | ||||
| Interferon alfa-2b inj | J9214 | ||||
| Inj, omacetaxine mep, 0.01mg | J9262 | ||||
| Sacituzumab govitecan-hziy | J9317 | 1/1/2021 | |||
| 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 | 4/1/2021 | ||
| Injection, lumasiran | C9074 | 4/1/2021 | 7/1/2021 | ||
| Injection, casimersen, 10 mg | C9075 | 7/1/2021 | 10/1/2021 | ||
| Loncastuximab-lpyl, 0.1 mg | C9084 | 10/1/2021 | |||
| Injection, glucarpidase | C9293 | ||||
| Injection, alemtuzumab | J0202 | ||||
| Alglucosidase alfa injection | J0220 | ||||
| Inj., patisiran, 0.1 mg | J0222 | ||||
| Inj givosiran 0.5 mg | J0223 | ||||
| Inj. lumasiran, 0.5 mg | J0224 | 7/1/2021 | |||
| Inj., cerliponase alfa 1 mg | J0567 | ||||
| Injection, burosumab-twza 1m | J0584 | ||||
| Inj., lanadelumab-flyo, 1 mg | J0593 | ||||
| Injection, casimersen, 10 mg | J1426 | 10/1/2021 | |||
| Inj. viltolarsen | J1427 | 4/1/2021 | |||
| Inj, eteplirsen, 10 mg | J1428 | ||||
| Inj golodirsen 10 mg | J1429 | ||||
| Galsulfase injection | J1458 | ||||
| Idursulfase injection | J1743 | 7/1/2021 | |||
| Inj. inebilizumab-cdon, 1 mg | J1823 | 1/1/2021 | |||
| Pegloticase injection | J2507 | 7/1/2021 | |||
| Inj, taliglucerase alfa 10 u | J3060 | 7/1/2021 | |||
| Inj. teprotumumab-trbw 10 mg | J3241 | ||||
| Inj., vestronidase alfa-vjbk | J3397 | ||||
| Inj luxturna 1 billion vec g | J3398 | ||||
| Inj onase abepar-xioi treat | J3399 | ||||
| Inj andexxa, 10 mg | J7169 | ||||
| Factor xiii recomb a-subunit | J7181 | ||||
| Ganciclovir long act implant | J7310 | ||||
| Afamelanotide implant, 1 mg | J7352 | 1/1/2021 | |||
| Erwinaze injection | J9019 | 7/1/2021 | |||
| Inj, aspara, rylaze, 0.1 mg | J9021 | 1/1/2022 | |||
| Inj., emapalumab-lzsg, 1 mg | J9210 | ||||
| Inj inotuzumab ozogam 0.1 mg | J9229 | 7/1/2021 | |||
| Pegaspargase injection | J9266 | 7/1/2021 | |||
| Mitomycin instillation | J9281 | 1/1/2021 | |||
| Inj. naxitamab-gqgk, 1 mg | J9348 | 7/1/2021 | |||
| 495 | Yes - carve out | 7/1/2012 | |||
| Sirolimus, oral | J7520 | ||||
| Oral busulfan | J8510 | ||||
| Cabergoline, oral 0.25mg | J8515 | ||||
| Capecitabine, oral, 150 mg | J8520 | ||||
| Capecitabine, oral, 500 mg | J8521 | ||||
| Methotrexate oral 2.5 mg | J8610 | ||||
| Nabilone oral | J8650 | ||||
| Temozolomide | J8700 | ||||
| Cisplatin 10 mg injection | J9060 | ||||
| Cytarabine hcl 100 mg inj | J9100 | ||||
| Etoposide injection | J9181 | ||||
| Fluorouracil injection | J9190 | ||||
| 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.
