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

NYS DOH - Never Pay Procedures Under APG Reimbursement

Effective January 1, 2022 - March 31, 2023
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    
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    

*Procedure codes listed as carve outs should not be billed using APGs. Indication as a carve out does not guarantee alternative payment.
**Procedure codes became obsolete effective 1/1/2017.
Yes = Procedure code is not payable in APGs but is available for billing on ordered ambulatory fee schedule.
No = Procedure code is not reimbursable by Medicaid. Service may be billable under an alternative procedure code.
TBD = At this time Medicaid Policy has not made a final determination regarding these procedures. Once a final determination has been made, they will be adjusted on this list or just added into the general APG logic.

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      
Inj, decitabine (sun pharma) J0893   1/1/2023  
Decitabine injection J0894      
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 CLASS III CHEMOTHERAPY DRUGS   Yes - carve out 12/1/2008  
Inj cyclophosphamd auromedic C9087   1/1/2022 3/31/2022
Busulfan injection J0594      
Pentastarch 10% solution J2513      
Arsenic trioxide injection J9017      
Asparaginase, nos J9020      
Inj, bortezomib, nos, 0.1 mg J9044     12/31/2022
Inj, bortezomib, dr. reddy's J9046   1/1/2023  
Inj, bortezomib freseniuskab J9048   1/1/2023  
Inj, bortezomib, hospira J9049   1/1/2023  
Inj cladribine per 1 mg J9065      
Cyclophosphamide 100 mg inj J9070      
Inj cyclophosphamd auromedic J9071   4/1/2022  
Daunorubicin injection J9150      
Daunorubicin citrate inj J9151      
Mechlorethamine hcl inj J9230      
Mitoxantrone hydrochl / 5 mg J9293      
Inj, fulvestrant (teva) J9393   1/1/2023  
Inj, fulvestrant (fresenius) J9394   1/1/2023  
Injection, fulvestrant J9395      
Flutamide 125 mg S0175      
433 CLASS IV CHEMOTHERAPY DRUGS   Yes - carve out 12/1/2008  
Injection, bortezomib, 0.1mg J9041      
Degarelix injection J9155      
Inj. infugem, 100 mg J9198      
Mitomycin injection J9280      
Streptozocin injection J9320      
Thiotepa injection J9340      
434 CLASS V CHEMOTHERAPY DRUGS   Yes - carve out 12/1/2008  
Cidofovir injection J0740      
Leuprolide inj, camcevi, 1mg J1952   1/1/2022  
Inj lutrate depot 7.5 mg J1954   1/1/2023  
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 CLASS VI CHEMOTHERAPY DRUGS   Yes - carve out 1/1/2010  
Dexrazoxane hcl injection J1190      
Triptorelin pamoate J3315      
Inj, omacetaxine mep, 0.01mg J9262      
Temsirolimus injection J9330      
443 CLASS VII CHEMOTHERAPY DRUGS   Yes - carve out 1/1/2011  
Adalimumab injection J0135      
Denosumab injection J0897      
Monoclonal antibodies J7505      
Aldesleukin injection J9015      
Interferon alfa-2b inj J9214      
Sacituzumab govitecan-hziy J9317      
Sermorelin acetate injection Q0515      
465 CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY   Yes - carve out 7/1/2011  
Botulism ig iv 90288      
Injection, caplacizumab-yhdp C9047      
Loncastuximab-lpyl, 0.1 mg C9084     3/31/2022
Inj, tebentafusp-tebn, 1 mcg C9095   7/1/2022 9/30/2022
Injection, glucarpidase C9293      
Injection, alemtuzumab J0202      
Alglucosidase alfa injection J0220      
Inj., patisiran, 0.1 mg J0222      
Inj. lumasiran, 0.5 mg J0224      
Inj, vutrisiran, 1 mg J0225   1/1/2023  
Inj., cerliponase alfa 1 mg J0567      
Injection, burosumab-twza 1m J0584      
Inj., lanadelumab-flyo, 1 mg J0593      
Injection, casimersen, 10 mg J1426      
Inj. viltolarsen J1427      
Inj, eteplirsen, 10 mg J1428      
Inj golodirsen 10 mg J1429      
Galsulfase injection J1458      
Idursulfase injection J1743      
Inj. inebilizumab-cdon, 1 mg J1823      
Pegloticase injection J2507      
Inj, taliglucerase alfa 10 u J3060      
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      
Inj., retisert, 0.01 mg J7311      
Afamelanotide implant, 1 mg J7352      
Erwinaze injection J9019      
Inj, aspara, rylaze, 0.1 mg J9021   1/1/2022  
Inj inotuzumab ozogam 0.1 mg J9229      
Pegaspargase injection J9266      
Inj tisotu vedotin-tftv, 1mg J9273   4/1/2022  
Inj, tebentafusp-tebn, 1 mcg J9274   10/1/2022  
Mitomycin instillation J9281      
Inj. naxitamab-gqgk, 1 mg J9348      
Inj lon tesirin-lpyl 0.075mg J9359   4/1/2022  
495 MINOR CHEMOTHERAPY DRUGS   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.
**Refer to "Never Pay Procedures" list to verify whether a procedure of APG 385 has alternative