Specialty Drug Billing & Coding References

🔍 188 drugs

Billing reference library

When a drug page says "use JW modifier" or "bill 96413," the deep-dive is one click away. Sourced from CMS IOM, AMA CPT, NCCI edits, MAC LCDs, and payer policy documents.

Modifier reference ›

10 references

JW · JZ · JG/TB (340B) · KX · GA/GZ/GY (ABN) · RT/LT/E1-E4 (eye) · biosimilar suffix conventions

CPT admin codes ›

9 references

96365/66 IV biologics · 96413/15 chemo · 96417 sequential push · 96369/71 SCIG · 96360/61 hydration · 67028 intravitreal

Payer playbooks ›

4 playbooks

UnitedHealthcare · Aetna · Cigna · Humana — PA workflows, portals, fax numbers, biosimilar mandates, denials, reauth

Abecma

idecabtagene vicleucel (anti-BCMA CAR-T)

Q2055

R/R multiple myeloma (anti-BCMA CAR-T, BMS/2seventy; FIRST BCMA CAR-T; 4-1BB costim; KarMMa-3 to 2L April 2024; ~$560K/dose)

Abraxane

paclitaxel protein-bound (nab-paclitaxel)

J9264

Metastatic breast, NSCLC (combo), pancreatic adenocarcinoma (combo)

Actemra / biosimilars

tocilizumab + Tofidence, Tyenne, Avtozma

J3262 Q5135

RA, JIA, GCA, CRS, COVID, SSc-ILD

Acthar Gel

corticotropin (repository)

J0801 J0802

MS exacerbations, infantile spasms, multiple rheum/derm/renal indications (SC/IM)

Adcetris

brentuximab vedotin

J9042

Hodgkin lymphoma, ALCL, PTCL, CTCL (anti-CD30 ADC)

Aldurazyme

laronidase

J1931

MPS I (Hurler/Hurler-Scheie/Scheie) ERT (IV weekly)

Alhemo

concizumab-mtci

J7173

Hemophilia A/B prophylaxis incl. inhibitors (SC daily, anti-TFPI; J7173 = 0.5 mg/unit)

Alyglo

immune globulin IV 10% (GC Biopharma)

J1552

PI (lowest IgA content — IgA-deficient niche)

Amvuttra

vutrisiran

J0225

hATTR-PN + ATTR-CM (SC q3mo siRNA, HELIOS-B 2025)

Andexxa

andexanet alfa (Factor Xa decoy)

J7169

Emergency reversal of apixaban/rivaroxaban anticoagulation (NOT edoxaban, NOT dabigatran→Praxbind); ED single-encounter; low/high dose stratification; BOXED thrombotic warning

Aranesp

darbepoetin alfa

J0881 J0882

Long-acting ESA (CKD anemia + CIA; non-ESRD vs ESRD codes)

Argatroban

argatroban (multi-generic; Acova discontinued)

J0883 J0884 J0891 J0892 J0898 J0899

HIT-specific direct thrombin inhibitor (continuous IV titrated to aPTT 1.5-3× baseline; J0883 non-ESRD vs J0884 ESRD on dialysis — RENAL STATUS split, not payer; J0891/J0892 Accord + J0898/J0899 Auromedics non-equivalent codes)

Avastin / biosimilars

bevacizumab + Mvasi, Zirabev, Alymsys, Vegzelma, Avzivi

J9035 Q5107 Q5118 Q5126 Q5129 Q5145

mCRC, NSCLC, GBM, RCC, cervical, ovarian, HCC

Bendeka

bendamustine HCl (premixed)

J9034

CLL, indolent NHL, MCL (10-min infusion vs Treanda J9033)

Benlysta

belimumab

J0490

SLE + lupus nephritis (anti-BAFF IV q4wk; pediatric ≥5 yr)

C1 esterase inhibitor (human)

J0597

HAE acute attack treatment (IV on-demand)

Besponsa

inotuzumab ozogamicin

J9229

R/R B-cell precursor ALL (anti-CD22 ADC, calicheamicin payload)

Bimzelx

bimekizumab-bkzx (IL-17A/F)

J3590

Plaque psoriasis + PsA + AS + HS (dual IL-17A/F vs Cosentyx/Taltz IL-17A-only; UCB; SC q4w → q8w psoriasis, q4w PsA/AS/HS; pharmacy benefit dominant)

Bivalirudin / Angiomax

bivalirudin (multi-generic; Angiomax)

J0583

Direct thrombin inhibitor for PCI ± HIT (defensive content — J0583 is OPPS SI=N packaged + MS-DRG bundled; NOT separately payable in PCI; titrated to ACT 300-350 sec)

Bizengri

zenocutuzumab-zbco

J9382

NRG1+ NSCLC + pancreatic (HER2/HER3 bispecific, 750 mg flat q2w; NRG1 NGS gate)

Botox

onabotulinumtoxinA (therapeutic)

J0585

Chronic migraine, dystonia, spasticity, overactive bladder, hyperhidrosis (chemodenervation; units not interchangeable across toxins)

Breyanzi

lisocabtagene maraleucel (anti-CD19 CAR-T)

Q2054

LBCL + CLL/SLL + FL + MCL (anti-CD19 CAR-T, BMS; 4-1BB costim, 1:1 CD8:CD4 ratio — lowest CRS; first CAR-T for CLL via TRANSCEND CLL 004; ~$562K/dose)

Brineura

cerliponase alfa (recombinant TPP1 ICV ERT)

J0567

CLN2 disease / Batten ≥3 yr (FIRST CLN2 treatment; BioMarin; intracerebroventricular via Ommaya reservoir; CPT 96450 NOT 96365; 300 mg q2w; ~$702K/yr)

Briumvi

ublituximab-xiiy

J2329

Relapsing forms of MS (RRMS, active SPMS, CIS — not PPMS)

Carboplatin

carboplatin (multi-generic; Paraplatin discontinued)

J9045

Ovarian, NSCLC, SCLC, HNSCC, bladder (2nd-gen platinum; Calvert formula AUC × [GFR+25]; J9045 = 50 mg/unit)

Carvykti

ciltacabtagene autoleucel (anti-BCMA CAR-T)

Q2056

R/R multiple myeloma (anti-BCMA CAR-T, J&J/Legend; dual BCMA-binding-domain construct; parkinsonism/MNT delayed neurotox; CARTITUDE-4 to 2L April 2024; ~$623K/dose)

Casgevy

exagamglogene autotemcel (exa-cel)

J3590

SCD + TDT ≥12 yr (one-time CRISPR-edited autologous HSC, Vertex/CRISPR Tx; multi-stage encounter; ATC-restricted; ~$2.2M)

Cerezyme

imiglucerase

J1786

Type 1 Gaucher disease ERT (IV)

Cimerli

ranibizumab-eqrn (Lucentis biosimilar)

Q5128

wAMD + DME + RVO + mCNV (interchangeable Lucentis biosimilar; Q5128 = 0.1 mg/unit; CPT 67028 intravitreal; NO pediatric ROP — use J2778 Lucentis)

Cimzia

certolizumab pegol

J0717

RA, PsA, AS, axSpA, plaque psoriasis, Crohn's

Cinqair

reslizumab

J2786

Severe eosinophilic asthma (IV, eos ≥400)

Cinryze

C1 esterase inhibitor (human)

J0598

HAE prophylaxis (IV q3-4d, plasma-derived)

Cisplatin

cisplatin (multi-generic; Platinol discontinued)

J9060

HNSCC, NSCLC, SCLC, ovarian, bladder, testicular GCT (1st-gen platinum; aggressive hydration; preserved multi-dose vial — NO JW/JZ; J9060 = 10 mg/unit)

Columvi

glofitamab-gxbm

J9286

R/R DLBCL (CD20×CD3 IV bispecific, fixed 12-cycle)

Cosentyx

secukinumab

J3247

PsA, AS, plaque psoriasis

Cubicin

Daptomycin

J0878

cSSSI (4 mg/kg), S. aureus bacteremia/endocarditis (6 mg/kg); once-daily OPAT workhorse; not for pneumonia

PiaSky

crovalimab-akkz (anti-C5)

J1307

PNH ≥13 yr ≥40 kg (anti-C5 mAb; weight-banded loading + SC q4wk maintenance; J1307 = 10 mg/unit; PIASKY REMS SEPARATE from Soliris/Ultomiris REMS)

Crysvita

burosumab-twza

J0584

X-linked hypophosphatemia + tumor-induced osteomalacia (anti-FGF23 SC)

Cutaquig

immune globulin SC 16.5% (Octapharma)

J1551

PI (SCIG, only 16.5% concentration)

Cuvitru

immune globulin SC 20% (Takeda)

Gastric/GEJ + NSCLC + mCRC + HCC (anti-VEGFR2; indication-specific dosing 8-10 mg/kg; HCC requires AFP ≥400; J9308 = 5 mg/unit)

Dalvance

Dalbavancin

J0875

ABSSSI — single 1,500 mg infusion (zero-waste 3-vial JZ) replaces weeks of vancomycin OPAT

Darzalex

daratumumab (IV)

J9145

Multiple myeloma, AL amyloidosis

Darzalex Faspro

daratumumab + hyaluronidase-fihj (SC)

J9144

Multiple myeloma, AL amyloidosis (SC formulation)

Datroway

datopotamab deruxtecan-dlnk

J9011

HR+/HER2- mBC + EGFR+ NSCLC (TROP-2 ADC q3w; use D5W diluent)

Doxil / Lipodox

doxorubicin HCl liposomal (pegylated)

Q2050

Ovarian (post-platinum), Kaposi, MM (combo with bortezomib)

Doxorubicin

doxorubicin (multi-generic; Adriamycin)

J9000

Breast (AC), DLBCL (R-CHOP), Hodgkin (ABVD), AML, sarcoma (anthracycline; vesicant; 450-550 mg/m² lifetime cardiac cap; distinct from Doxil Q2050)

Elaprase

idursulfase

J1743

MPS II (Hunter) ERT (IV weekly)

Elelyso

taliglucerase alfa

J3060

Type 1 Gaucher ERT (IV q2w, 60 units/kg; first FDA plant-cell expressed therapeutic; J3060 = 10 units/billing unit)

Elfabrio

pegunigalsidase alfa-iwxj

J2508

Fabry disease ERT (IV q2wk PEGylated; vs Fabrazyme J0180)

Elrexfio

elranatamab-bcmm

J1323

R/R multiple myeloma (BCMA×CD3 SC bispecific, REMS)

Empliciti

elotuzumab

J9176

Relapsed/refractory multiple myeloma

Enhertu

fam-trastuzumab deruxtecan-nxki

J9358

HER2+/low/ultralow breast, HER2+ gastric, HER2+ NSCLC, tumor-agnostic

R/R DLBCL, FL (CD20×CD3 SC bispecific)

Epogen / Procrit

epoetin alfa

J0885

Short-acting ESA (CKD anemia, CIA, surgery, HIV)

Evenity

romosozumab-aqqg

J3111

Postmenopausal osteoporosis high fracture risk (sclerostin inhibitor; 210 mg monthly = 2 × 105 mg SC = 96372 × 2; BOXED CV warning; max 12 monthly doses then transition to antiresorptive)

aflibercept (8 mg high-dose)

J0177

wAMD, DME, DR, RVO (high-dose formulation)

Fabrazyme

agalsidase beta

J0180

Fabry disease ERT (IV q2wk)

Fasenra

benralizumab

J0517

Severe eos asthma, EGPA (q4wk×3 → q8wk SC)

Faslodex

fulvestrant (originator + generics)

J9395

HR+/HER2- mBC (CDK4/6 combo SOC; bilateral IM)

Feraheme

ferumoxytol

Q0138 Q0139

IDA (IV, 510 mg ×2; non-ESRD vs ESRD codes; Boxed)

Firmagon

degarelix

J9155

Advanced prostate cancer (GnRH antagonist, no flare)

Gamifant

emapalumab-lzsg

J9210

Primary HLH + 2025 Still's-MAS sBLA (anti-IFN-γ mAb; 1 mg/kg q3d escalating to 10 mg/kg; PICU induction DRG-bundled, outpatient bridge-to-HSCT Part B; HLH-2004 criteria gate)

Gammagard Liquid

immune globulin IV 10% (Takeda)

J1569

PI, MMN, off-label CIDP / SID

Gamunex-C / Gammaked

immune globulin IV 10% (Grifols / Kedrion)

J1561

PI, ITP, CIDP (IV + SC)

Gazyva

obinutuzumab

J9301

CLL 1L + FL (post-rituximab) + Columvi pretreatment Day -7 (anti-CD20 Type II glycoengineered; HBV screen mandatory; 1000 mg flat dose; J9301 = 10 mg/unit)

Gemcitabine

gemcitabine (Gemzar + generics)

J9201

Pancreatic, NSCLC, breast, ovarian, bladder, biliary

Generic IV Chemotherapy Reference

cyclophosphamide + 5-FU + cytarabine + 15 more (rollup)

J9070 J9192 J9100 J9208 J9209

Generic IV chemo rollup (long-tail, NOT in dedicated pages) — cyclophosphamide anchor (J9070); multi-dose vial JZ/JW exclusion; 96416 vs 96417 portable pump trap

Givlaari

givosiran

J0223

Acute hepatic porphyria attack reduction (SC monthly siRNA)

Haegarda

C1 esterase inhibitor SC (human)

J0599

HAE prophylaxis (SC q3-4d, plasma-derived)

Hemgenix

etranacogene dezaparvovec-drlb

J1411

Adult hemophilia B (one-time AAV5 IV gene therapy, CSL Behring; AAV5 NAb <1:678 gate; world's most expensive drug at ~$3.5M)

Hemlibra

emicizumab-kxwh

J7170

Hemophilia A prophylaxis (both inhibitor + non-inhibitor; FVIII bispecific SC weekly/q2w/q4w; J7170 = 0.5 mg/unit; cheaper per unit than Alhemo; Feiba/aPCC boxed warning)

Herceptin / biosimilars

trastuzumab + Ontruzant, Herzuma, Ogivri, Trazimera, Kanjinti, Hercessi

J9355 Q5112 Q5113 Q5114 Q5116 Q5117 Q5146

HER2+ breast cancer, HER2+ gastric

Hizentra

immune globulin SC 20% (CSL)

J1559

PI, CIDP maintenance (SCIG via pump)

Humira / biosimilars

adalimumab + Amjevita, Cyltezo, Hadlima, Hyrimoz

J0139 Q5140 Q5141 Q5142 Q5143 Q5144 Q5145

RA, PsA, AS, Crohn's, UC, plaque psoriasis

Ilaris

canakinumab

J0638

Periodic fever syndromes (CAPS, SJIA, AOSD, TRAPS, HIDS-MKD, FMF) — anti-IL-1β SC q4-8w; J0638 = 1 mg/unit; genetic testing PA gate (NLRP3/MEFV/MVK/TNFRSF1A)

Rytelo

imetelstat

J0870

Low/int-1 MDS post-ESA failure (telomerase inhibitor IV q4w; 7.1 mg/kg actual weight)

Imfinzi

durvalumab

J9173

NSCLC (PACIFIC), SCLC (ADRIATIC), HCC, biliary, urothelial, endometrial

Imjudo

tremelimumab-actl

J9347

HCC (HIMALAYA STRIDE single 300 mg priming + Imfinzi) + NSCLC (POSEIDON 75 mg q3w × 5 + chemo + Imfinzi) — CTLA-4 inhibitor, J9347 = 1 mg/unit

INFeD

iron dextran

J1750

IDA (IV, requires test dose; Boxed)

Injectafer

ferric carboxymaltose

J1439

IDA (IV, 750 mg ×2; HF + pediatric expansions)

Irinotecan

irinotecan (multi-generic; Camptosar)

J9206

CRC (FOLFIRI/FOLFIRINOX), pancreatic, gastric (topo-I inhibitor q2w; UGT1A1*28 dose-adjust; J9206 = 20 mg/unit; distinct from Onivyde J9205)

IV Anesthesia & Sedation Reference

propofol + midazolam + fentanyl + 9 more (rollup)

J2704 J2250 J3010

IV anesthesia/sedation rollup — propofol anchor (J2704); USUALLY BUNDLED into 00xxx anesthesia time / APC packaging / ICU per-diem; J0480 ≠ flumazenil (= basiliximab), J2786 ≠ sugammadex (= reslizumab)

IV Antibiotics Reference

vancomycin + daptomycin + 13 more (rollup)

J3370 J3373 J0878 J2020 J0714 J2186

HOPD/OPAT IV antibiotics rollup — vancomycin anchor (J3370/J3373); MRSA/VRE/CRE/CRAB landscape; OPAT PA gates

IV Antifungals Reference

AmBisome + caspofungin + 10 more (rollup)

J0289 J0637 J2248 J0348

IV antifungals rollup — AmBisome anchor (J0289); 3 classes (polyenes, echinocandins, azoles); ID consult + biomarker gates (galactomannan, BD-glucan)

IV Antivirals Reference

acyclovir + ganciclovir + 6 more (rollup)

J0133 J1570 J1455 J0740

IV antivirals rollup (excl. Veklury) — acyclovir anchor (J0133); CMV in transplant focus; foscarnet nephrotoxicity; cidofovir highest-cost

IV Fluids & Electrolytes Reference

NS + LR + D5W + KCl + Mg + Ca + 6 more (rollup)

J7030 J7040 J7050 J7120 J7070

IV fluids + electrolytes rollup — NS anchor (J7030); 96360/96361 hydration vs 96365/96366 drug-admin trap; chemo-vehicle bundling rules

IV Vitamins & Supplements Reference

B12 + vitamin K + thiamine + 7 more (rollup)

J3420 J3430 J3411 J1610 J1955

IV vitamins/supplements rollup — cyanocobalamin/B12 anchor (J3420); B12 IM vs IV trap; J0643 = leucovorin (NOT plain folate); TPN bundling defensive framing

Jemperli

dostarlimab-gxly

J9272

dMMR/MSI-H endometrial (RUBY 1L), tumor-agnostic dMMR

Kadcyla

ado-trastuzumab emtansine (T-DM1)

J9354

HER2+ mBC + early-stage residual disease post-neoadjuvant (KATHERINE); 3.6 mg/kg q3w; ADC with DM1 payload; HER2-low routes to Enhertu

Kanuma

sebelipase alfa

J2840

LAL-D / Wolman disease + CESD (lysosomal ERT; Wolman 1-3 mg/kg weekly, CESD 1 mg/kg q2w; LAL enzyme assay required; Wolman → Medicaid-primary)

Keytruda

pembrolizumab

J9271

Multiple solid tumor & hematologic indications

Keytruda Qlex

pembrolizumab + berahyaluronidase alfa (SC)

J9277

Most Keytruda IV indications (SC formulation, 395 mg q3w or 790 mg q6w)

Kimyrsa

Oritavancin

J2406

ABSSSI — single 1,200 mg / 1-hour infusion (zero-waste JZ); not the same code as Orbactiv (J2407); 120-hr heparin hold

Kisunla

donanemab-azbt

J0175

Early symptomatic Alzheimer's (q4wk anti-amyloid IV)

Kymriah

tisagenlecleucel (anti-CD19 CAR-T)

Q2042

Peds ALL + adult DLBCL/FL (anti-CD19 CAR-T, Novartis; 4-1BB costim; KymriahCares hub; MS-DRG 018; ~$614K/dose; multi-stage encounter)

Kyprolis

carfilzomib

J9047

R/R multiple myeloma (2nd-gen proteasome inhibitor IV)

Legacy Direct Thrombin Inhibitors

desirudin + lepirudin + fondaparinux (rollup)

J0838 J1652

Legacy DTIs rollup — desirudin anchor (J0838, not in CMS ASP); lepirudin withdrawn 2012; Fondaparinux CONTRAINDICATED in HIT

Lemtrada

alemtuzumab

J0202

Relapsing forms of MS

Leqembi

lecanemab-irmb

J0174

Early symptomatic Alzheimer's (q2wk anti-amyloid IV)

Leqvio

Inclisiran

J1306

Twice-yearly LDL-C siRNA — fixed 284 mg/284 units, subQ injection (96372, not infusion)

Libtayo

cemiplimab-rwlc

J9119

Cutaneous SCC (1st FDA), BCC, NSCLC, cervical

Lucentis / biosimilars

ranibizumab + Byooviz, Cimerli

J2778 Q5124

wAMD, DME, RVO, mCNV, ROP

Lunsumio

mosunetuzumab-axgb

J9350

R/R follicular lymphoma (CD20×CD3 IV bispecific, fixed-duration)

Lupron Depot

leuprolide acetate (long-acting depot)

J1950

Prostate cancer, endometriosis, fibroids, central precocious puberty

Lutathera

lutetium Lu 177 dotatate

A9513

GEP-NETs (PRRT radioligand, Novartis; CPT 79101 NOT 96365; Ga-68/Cu-64 dotatate PET gate; HOPD-only NRC; ~$56K/dose × 4)

Lyfgenia

lovotibeglogene autotemcel (lovo-cel)

J3590

SCD ≥12 yr only — NO TDT (one-time lentiviral autologous HSC, Bluebird Bio; BOXED hematologic malignancy warning; QTC-restricted; ~$3.1M)

Mircera

methoxy PEG-epoetin beta

J0888

CKD-only ESA (q4wk longest-acting; CKD-only positioning)

Monoferric

ferric derisomaltose

J1437

IDA (IV, 1,000 mg single-dose course)

Mylotarg

gemtuzumab ozogamicin

J9203

CD33+ AML newly diagnosed + R/R (anti-CD33 ADC with calicheamicin payload; fractionated D1/D4/D7 induction; J9203 = 0.1 mg/unit; BOXED hepatotoxicity/VOD)

Naglazyme

galsulfase

J1458

MPS VI (Maroteaux-Lamy) ERT (IV weekly)

Neulasta + biosimilars

pegfilgrastim

J2506 Q5108 Q5111 Q5120 Q5122 Q5125

Long-acting G-CSF for chemo-induced neutropenia prevention

Neupogen + biosimilars

filgrastim + Zarxio, Nivestym, Releuko, Nypozi

J1442 Q5101 Q5110 Q5125

Chemo-induced neutropenia, BMT (G-CSF SC daily, weight-based; J1442 = 1 mcg/unit)

Nucala

mepolizumab

J2182

Severe eos asthma, EGPA, HES, CRSwNP (anti-IL-5 SC)

Nulojix

belatacept (CTLA-4-Ig)

J0485

Kidney transplant rejection prophylaxis (EBV-seropositive REMS; 10 mg/kg initial 6 doses → 5 mg/kg q4w maintenance; J0485 = 1 mg/unit; NOT for liver transplant per boxed warning)

ocrelizumab and hyaluronidase-ocsq (SC)

J2351

RRMS, PPMS, SPMS (subcutaneous)

Octagam

immune globulin IV 5% / 10% (Octapharma)

J1568

PI, ITP, dermatomyositis (10%)

Omvoh

mirikizumab-mrkz

J2267

Ulcerative colitis + Crohn's disease (anti-IL-23p19; 300 mg IV q4w × 3 induction → 200 mg SC q4w maintenance; SC CAN bill medical under J2267, distinct from Skyrizi/Tremfya SC pharmacy-only)

Onivyde

irinotecan liposomal (pegylated)

J9205

Metastatic pancreatic adenocarcinoma (NALIRIFOX 1L 2024)

Onpattro

patisiran

J0222

hATTR-PN (IV q3wk siRNA)

Opdivo

nivolumab

J9299

Melanoma, NSCLC, RCC, others

Opdivo Qvantig

nivolumab + hyaluronidase-nvhy (SC)

J9289

Most Opdivo solid tumor indications (SC formulation; J9289 = 2 mg/unit)

Opdualag

nivolumab + relatlimab-rmbw

J9298

Unresectable/metastatic melanoma 1L (first-in-class LAG-3 + PD-1 fixed-dose combo; 480/160 mg q4w; J9298 = 3 mg nivo + 1 mg rela/unit; distinct from Opdivo J9299 + Opdivo Qvantig J9289)

Orencia

abatacept

J0129

RA, JIA, PsA, aGVHD prevention

Oxaliplatin

oxaliplatin (Eloxatin + generics)

J9263

CRC (FOLFOX), gastric (FLOT), pancreatic (FOLFIRINOX)

Paclitaxel

paclitaxel conventional (multi-generic; Taxol)

J9267

Breast, ovarian, NSCLC, HNSCC (3-hr IV with premed; Cremophor vehicle + in-line filter; multi-dose vial JZ-default; distinct from Abraxane J9264)

Padcev

enfortumab vedotin-ejfv

J9177

Locally advanced/metastatic urothelial cancer (Keytruda combo 1L + post-platinum mono)

Pemetrexed

pemetrexed (Alimta + generics)

J9305

Non-squamous NSCLC, mesothelioma (vitamin supp + CrCl)

Perjeta

pertuzumab

J9306

HER2+ breast cancer (combo with Herceptin)

Phesgo

pertuzumab + trastuzumab + hyaluronidase-zzxf (SC)

J9316

HER2+ breast cancer (SC fixed-dose combo Q3W; J9316 = 10 mg pertuzumab/unit; CPT 96401; distinct from Perjeta J9306 + Herceptin J9355 IV components)

Pluvicto

lutetium Lu 177 vipivotide tetraxetan

A9607

PSMA+ mCRPC (PSMA radioligand, Novartis; CPT 79101; Pylarify/Locametz PSMA-PET gate; March 2025 pre-taxane expansion; ~$42K/dose × 6)

Polivy

polatuzumab vedotin-piiq

J9309

DLBCL 1L (POLARIX with R-CHP) + R/R DLBCL

Poteligeo

mogamulizumab-kpkc

J9204

R/R cutaneous T-cell lymphoma — MF/Sézary (anti-CCR4 mAb; 1 mg/kg q1w × 4 → q2w; J9204 = 1 mg/unit; W&P-level warnings, not boxed)

Privigen

immune globulin IV 10% (CSL)

J1459

PI, ITP, CIDP

Prolia / Jubbonti + biosimilars

denosumab + Jubbonti, Stoboclo

J0897 Q5136 Q5157 Q5158

Postmenopausal osteoporosis + AI/ADT-induced bone loss (60 mg SC q6mo; vs Xgeva 120 mg q4wk for cancer SREs)

Denosumab biosimilars

All Prolia & Xgeva biosimilars compared

Q5136 Q5157 Q5162 Q5167

Every denosumab biosimilar: Q-code, maker, Medicare price per dose, payer preference

Beta-thalassemia + MDS transfusion-dependent anemia (SC)

Remicade / biosimilars

infliximab + Inflectra, Renflexis, Avsola

J1745 Q5103 Q5104 Q5121

RA, AS, PsA, psoriasis, Crohn's, UC

epoetin alfa-epbx (biosimilar)

Q5106 Q5105

Rituxan / biosimilars

rituximab + Ruxience, Truxima, Riabni

J9312 Q5119 Q5115

NHL, CLL, RA, GPA/MPA

Rocephin

Ceftriaxone

J0696

Broad-spectrum OPAT workhorse (1–2 g q24h, flat dose); confirmed off every MAC's SAD list; zero-waste JZ; generic, no copay card

Roctavian

valoctocogene roxaparvovec-rvox

J1412

Adult severe hemophilia A (one-time AAV5 IV gene therapy, BioMarin; AAV5 NAb-negative + no FVIII inhibitor history required; ~$2.9M)

Ruconest

C1 esterase inhibitor recombinant

J0596

HAE acute attack treatment (IV on-demand, recombinant)

Rystiggo

rozanolixizumab-noli

J9333

Generalized myasthenia gravis (AChR+ AND MuSK+; FcRn inhibitor 7 mg/kg SC weekly × 6 per cycle; J9333 = 1 mg/unit; covers MuSK+ unlike Vyvgart)

Sandostatin / LAR Depot

octreotide acetate

J2354 J2353

Acromegaly + carcinoid + NETs (SC non-depot vs IM LAR depot)

Saphnelo

anifrolumab-fnia

J0491

Moderate-severe SLE (anti-IFN-α/β receptor IV q4wk)

Sarclisa

isatuximab-irfc

J9227

Multiple myeloma (anti-CD38, IMROZ 1L 2024)

Simponi Aria

golimumab (IV)

J1602

RA, PsA, AS, polyarticular JIA

Skyrizi (IV induction)

risankizumab-rzaa

J2327

Crohn's + UC IV induction (IL-23, → SC maintenance)

Soliris / biosimilars

eculizumab + Epysqli, Bkemv

J1299 Q5151 Q5152

PNH, aHUS, gMG, NMOSD

Solu-Medrol + generics

methylprednisolone sodium succinate IV

J2919

Chemo premed, MS pulse (1g×3-5d), transplant rejection, severe asthma, anaphylaxis (NOT chemo — 96365/96374 not 96413; J2919 = 5 mg/unit)

Somatuline Depot

lanreotide acetate (deep SC depot)

J1930

Acromegaly + GEP-NETs + carcinoid syndrome (SSA depot deep SC q4w; CPT varies by indication 96372/96401)

Spinraza

nusinersen (intrathecal ASO)

J2326

SMA all types + ages (intrathecal LP via CPT 62321 — NOT 96365; loading + q4mo maintenance; SMN1 confirmation; Biogen Above SMA)

Stelara / biosimilars

ustekinumab + Wezlana, Selarsdi, +more

J3357 J3358 Q5137 Q5138

PsA, plaque psoriasis, Crohn's, UC

Takhzyro

lanadelumab-flyo

J0593

HAE prophylaxis (SC q2-4wk mAb)

Talvey

talquetamab-tgvs

J3055

R/R multiple myeloma (GPRC5D×CD3 SC bispecific, REMS)

Tecartus

brexucabtagene autoleucel (anti-CD19 CAR-T)

Q2053

R/R MCL post-BTKi + adult R/R ALL (anti-CD19 CAR-T, Kite; T-cell enrichment manufacturing for peripheral disease; ZUMA-2/3; ~$489K/dose)

Tecentriq

atezolizumab

J9022

NSCLC, SCLC, HCC, urothelial, TNBC, melanoma, sarcoma

Tecvayli

teclistamab-cqyv

J9380

R/R multiple myeloma (BCMA×CD3 SC bispecific, REMS)

Emrelis (Teliso-V)

telisotuzumab vedotin-tllv

J9326

c-MET HIGH overexpression NSCLC post-systemic therapy (c-MET ADC q2w; VENTANA MET SP44 IHC ≥50%)

Tepezza

teprotumumab-trbw

J3241

Thyroid Eye Disease (IGF-1R inhibitor; 8-infusion course 10→20 mg/kg q3w; CAS ≥3 required; J3241 = 10 mg/unit; ~$423K course total)

Tevimbra

tislelizumab-jsgr

J9329

ESCC + HER2-neg G/GEJ (PD-1 IV q3w; NSCLC EU/China only, not US label)

Tezspire

tezepelumab-ekko

J2356

Severe persistent asthma add-on regardless of phenotype (anti-TSLP class-of-one; 210 mg SC q4w; no biomarker gate)

Tivdak

tisotumab vedotin-tftv

J9273

Recurrent/metastatic cervical cancer (anti-tissue-factor ADC)

Tremfya (IV induction)

guselkumab

J1628

Crohn's + UC IV induction (IL-23) + psoriasis/PsA SC

Trodelvy

sacituzumab govitecan-hziy

J9317

Metastatic TNBC, HR+/HER2- metastatic breast, urothelial

Tyruko

natalizumab-sztn (biosimilar)

Q5134

RRMS, Crohn's disease

Tysabri

natalizumab

J2323

RRMS, Crohn's disease

Tzield

teplizumab-mzwv

J9381

Delay onset of stage 3 T1D (14-day IV course, anti-CD3)

Ultomiris

ravulizumab-cwvz

J1303

PNH, aHUS, gMG, NMOSD

Uplizna

inebilizumab-cdon

J1823

NMOSD AQP4-IgG+ (2020) + IgG4-RD (2025) (anti-CD19 mAb; 300 mg D1+D15 loading → q6mo maintenance; J1823 = 1 mg/unit; $148K/dose)

mCRC RAS-WT (anti-EGFR; companion diagnostic gate; 6 mg/kg q2w; J9303 = 10 mg/unit; distinct from Erbitux — no premed required)

Veklury

remdesivir

J0248

COVID-19 antiviral (IV; 5-day inpatient or 3-day outpatient; inpatient typically DRG-bundled)

Velcade

bortezomib + Boruzu, generic

J9041 J9054 J9049

Multiple myeloma + MCL (proteasome inhibitor SC/IV)

Vibativ

Telavancin

J3095

MRSA cSSSI / HABP-VABP salvage lipoglycopeptide (boxed warnings); 750 mg vial only → JW waste; not routine OPAT

Venofer

iron sucrose

J1756

IDA in CKD (IV, HDD-CKD bundled into ESRD PPS)

Vimizim

elosulfase alfa

J1322

MPS IVA (Morquio A) ERT (IV weekly)

Voxzogo

vosoritide (CNP analog)

J3490

Pediatric achondroplasia ≥4 mo with open growth plates (BioMarin; weight-based daily SC; FGFR3 mutation + open growth plates required; ~$320K/yr)

VPRIV

velaglucerase alfa

J3385

Type 1 Gaucher ERT (IV q2w, 60 units/kg; J3385 = 100 units/billing unit)

Vyepti

eptinezumab-jjmr

J3032

Migraine prevention (episodic + chronic)

Vyloy

zolbetuximab-clzb (anti-claudin 18.2)

J1326

HER2-neg CLDN18.2+ gastric/GEJ 1L (first claudin 18.2 mAb, Astellas; VENTANA CLDN18 ≥75% 2+/3+ IHC required; combo with mFOLFOX6 or CAPOX; ~$5-7K/dose)

Vyvgart + Vyvgart Hytrulo

efgartigimod alfa-fcab (FcRn inhibitor)

J9332 J9334

AChR+ gMG (FcRn antagonist; IV J9332 + SC Hytrulo J9334; argenx; 10 mg/kg q1w × 4 per cycle; AChR+ ONLY — MuSK+ → Rystiggo)

Xembify

immune globulin SC 20% (Grifols)

ASMD / Niemann-Pick type B + A/B (first-in-class IV q2wk)

Xgeva + biosimilars

denosumab cancer-dose + Jubbonti, Wyost, Stoboclo

J0897 Q5136 Q5157 Q5158

Xolair

omalizumab

J2357

Allergic asthma, CSU, CRSwNP, food allergy (anti-IgE SC)

Yervoy

ipilimumab

J9228

Melanoma, RCC, MSI-H/dMMR CRC, HCC, NSCLC, esoph, mesothelioma (Opdivo combos)

Yescarta

axicabtagene ciloleucel (anti-CD19 CAR-T)

Q2041

DLBCL + FL + 2L LBCL (anti-CD19 CAR-T, Kite/Gilead; CD28 costim — higher CRS; ZUMA-7 brought CAR-T to 2L; Kite Konnect hub; ~$532K/dose)

Ziihera

zanidatamab-hrii

J9276

HER2+ biliary tract cancer (HER2/HER2 bispecific, Jazz; J9276 = 2 mg/unit; replaced C9302)

Zolgensma

onasemnogene abeparvovec-xioi

J3399

Pediatric SMA ≤2 yr (one-time AAV9 IV gene therapy, Novartis; AAV9 antibody titer <1:50 gate; outcomes-based contracting; ~$2.125M)

Zynlonta

loncastuximab tesirine-lpyl

J9359

R/R DLBCL after 2+ prior therapies (anti-CD19 ADC with PBD payload; 150 mcg/kg → 75 mcg/kg q3w; J9359 = 0.075 mg/unit; 3-day dex premed mandatory)

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