Part II
POLICIES AND PROCEDURES
FOR THE

PHYSICIANS’ INJECTABLE DRUG LIST

GEORGIA DEPARTMENT OF COMMUNITY HEALTH
DIVISION OF MEDICAL ASSISTANCE PLANS

Published October 1, 2013

PREFACE
The Physicians’ Injectable Drug List (PIDL) manual contains basic information regarding
Georgia’s Fee for Service (FFS) Medicaid and PeachCare for Kids programs and should be used in conjunction with Policies and Procedures Manual for Medicaid and PeachCare for Kids Part I,
Part II Policies and Procedures Manual for Physician Services, and other applicable program manuals. We urge you and your office staff to familiarize yourselves with the contents of this manual and refer to it when questions arise. Use of the manuals will assist in the elimination of misunderstandings concerning the coverage levels and billing procedures that can result in delays of claims processing or payments, inaccuracies and/or denials.
The PIDL is reviewed and updated quarterly, it is re-priced annually. Drugs that are not re-priced by the manufacturer or are no longer manufactured, or obsolete may not be re-priced or changed— refer to the Schedule of Maximum Allowable Payments (Appendix A) in this manual. For quality purposes, the PIDL is periodically purged of drugs with no or low (fewer than 50 units of service annually) utilization over a three (3) year period; except for orphan drugs and certain chemotherapeutic agents. Requests for coverage of purged drugs will be considered on a case-bycase basis.
When quarterly updates are made, they will be included in the manual posted on the fiscal agent’s,
Hewlett Packard’s (HP), website at www.mmis.georgia.gov, which shall constitute formal notice to providers. The amended provisions will be effective on the date of the notice or as specified by the notice itself, and all providers are responsible for complying with the amended manual provisions as of their effective dates.
Thank you for your participation and interest in Georgia’s Medicaid and PeachCare for Kids programs. Your service is greatly appreciated.

Physicians’ Injectable Drug List (PIDL) – October 2013

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PART II
POLICIES AND PROCEDURES
FOR THE

PHYSICIANS’ INJECTABLE DRUG LIST (PIDL)
CONTENTS
CHAPTER 600

SPECIAL CONDITIONS OF PARTICIPATION

VI

CHAPTER 700

SPECIAL ELIGIBILITY CONDITIONS

VII

CHAPTER 800

PRIOR APPROVAL

VIII

Section 801.1
Section 801.2

CHAPTER 900

Prior Approval (PA) Process for Injectable Drugs
PA Process for Prescription Drugs

SCOPE OF SERVICES
Section 901
Section 902
Section 903
903.1
903.2
Section 904
904.1
904.1a
904.2
904.3
904.4
904.5

CHAPTER 1000

IX

General
Coding of Claims
Billing Methodology for Injectable Drugs
General Claims Submission Policy for Ordering,
Prescribing, or Referring (OPR) Providers
Non-rebateable Injectable Drugs
Service Limitations
Immunizations and Vaccines
Administration
Vitamins
Hormones
Experimental Drugs/Unlabeled Use
Other Limitations

BASIS FOR REIMBURSEMENT
Section 1000

Reimbursement Methodology

Section 1001

Review and Record Keeping Requirements

Section 1002

X

Non-Covered Injectable Drugs and Services

APPENDIX A

Schedule of Maximum Allowable

APPENDIX B

Physicians’ Injectable Drug List Review Request Form (PRRF)

APPENDIX C

Georgia Families

Physicians’ Injectable Drug List (PIDL) – October 2013

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CHAPTER 600
SPECIAL CONDITIONS OF PARTICIPATION
601.

In addition to the general conditions of participation identified in Part I, Section 105, providers must meet all the conditions as outlined in the Physician Services Program in order to use the Physicians’ Injectable Drug List (PIDL).

601.1 Each enrolled physician agrees to bill the Division for only those services which are performed by the physician or under the physician’s direct supervision.

Physicians’ Injectable Drug List (PIDL) – October 2013

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CHAPTER 700
SPECIAL ELIGIBILITY CONDITIONS
There are no special eligibility conditions for physician diagnostic and treatment services.

Physicians’ Injectable Drug List (PIDL) – October 2013

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CHAPTER 800
PRIOR APPROVAL
801.

Services That Require Prior Approval
As a condition of reimbursement, the Division requires that certain services or procedures be approved prior to the time they are rendered. This process is called Prior Approval. It pertains to medical necessity only; the patient must be Medicaid-eligible at the time the service is rendered.
801.1

Prior Approval (PA) Process for Injectable Drugs
FDA approved injectable drugs listed on the Physicians’ Injectable Drug List
(PIDL) do not require prior authorization unless indicated. Effective for dates of service (DOS) on and after January 1, 2006, the Department began requiring
PA for specific injectable drugs administered in providers’ offices, outpatient hospitals, or other applicable outpatient settings. Injectable drugs requiring prior approvals (PAs) are indicated by this PA symbol.

Rev. 01/06

PA requests for injectable drugs must be submitted via the Georgia Web
Portal. The request must include applicable clinical information along with the corresponding ICD-9 diagnosis code, CPT or HCPCS code and corresponding
11-digit National Drug Code (NDC) number. Requests that are incomplete may be delayed or denied for insufficient information. Failure to obtain a PA will result in denial.
NOTE: Providers must be registered web users with active user identifications and passwords to submit requests for PA via the web.
For additional information or questions, please visit the Georgia Web Portal at www.mmis.georgia.gov using the ―Contact Us‖ feature.
801.2
Clarified 01/07

PA Process for Prescription Drugs (Outpatient Pharmacy)
PAs for prescription drugs on the Preferred Drug List (PDL) are handled through the Outpatient Pharmacy Program and are not considered through the
Physicians’ Injectable Drug PA process. Providers are discouraged from using written prescriptions through the outpatient pharmacy program to obtain injectable drugs for administration in the office setting, .
For detailed information pertaining to outpatient pharmacy prior approvals and related pharmacy services, refer to Part II Policies and Procedures Manual for
Pharmacy Services. The Pharmacy Services manual is accessible online at www.mmis.georgia.gov. Physicians’ Injectable Drug List (PIDL) – October 2013

V11I-1

CHAPTER 900
SCOPE OF SERVICES
901.

General
The Physicians’ Injectable Drug List program describes the reimbursement process for a broad range of injectable drugs, some immunizations and vaccines are subject to specific limitations as listed in the Manual. Federal regulations allow the state agency to place appropriate limits for medical necessity and utilization control. The Medicaid Division has developed reimbursement limitations to ensure appropriate utilization of funds. These limitations consist of (a) prior approval requirements described in Chapter 800 and (b) noncovered products described in Section 1003.
The PIDL is comprised of FDA approved injectable drugs that are to be administered in physicians’ offices or outpatient facilities by doctors or eligible staff. The injections must be reasonable, necessary and indicated for the diagnoses or effective treatments of specific illnesses or injuries based on accepted standards of medical practice. Requests to consider coverage of additional injectables or make changes to existing injectable drugs will be completed in the order received. The goal is to complete the review and respond to requests within 30 days of receipt of the completed form – Physicians’ Injectable Drug List Review
Request Form (PRRF). Forms are to be submitted electronically to pjeter@dch.ga.gov by clicking ‘submit’ at the top of the form. Products listed on incomplete forms will not be considered. The form is Appendix B of this manual and is also located on the website site at

Rev
Rev 01/11

Rev.10/12

http://dch.georgia.gov/provider-forms.
Therapeutic injections should be utilized only if equally effective oral medications cannot be prescribed without significant risks or increased side effects. Listed below in Section 904, are specific limitations in several coverage areas. Exceptions to these limitations will be considered if the provider can document the medical necessity of an injection.

902.

Coding of Claims - CPT and HCPCS Codes
The Department’s procedure coding encompasses the Health Care Common Procedure
Coding System (HCPCS) and Current Procedural Terminology (CPT) codes. The HCPCS coding scheme for injectable drugs includes the following levels of procedure codes:
a) Level II

Alphanumeric codes for covered Medicare and Medicaid services;

b) Level III Codes created by CMS or its intermediaries for services for which no Level II codes have been established. These codes begin with A, C, Q, or S.

Rev 07/12

Rev. 06/08

The Department does not accept all codes from these coding schemes. Georgia Medicaid covers only the codes for injectable drugs listed in Appendix A. HCPCS codes are drug and strength specific, therefore if the HCPCS code is listed in Appendix A, the drug, regardless of brand name is covered if it is rebateable.
The Department does not recognize unclassified HCPCS codes (J3490, J3590, J7599, J9999, etc.), not yet assigned a unique HCPCS/CPT code; except where the unclassified code has been temporarily assigned to newly approved injectable drugs; and is billed in conjunction with the corresponding NDC number.

Physicians’ Injectable Drug List (PIDL) – October 2013

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Administration fees for injectable drugs are not separately reimbursable under the Physician
Services program with the exception of chemotherapy administration codes 96401-96542.
Acquisition of a CPT code manual can be accomplished via mail at the address listed here:
CPT
Order Department OP054193
American Medical Association
Post Office Box 10950
Chicago, IL 60610

Rev. 04/05

903

Billing Methodology

Rev. 01/07

Effective April 1, 2003, the Physicians’ Injectable Drug List’s (PIDL) reimbursement methodology is consistent with HCPCS Level II dose and description. Local codes (X-codes) are no longer reimbursable when billing injectable drugs.

Rev. 01/07

Effective January 1, 2007 and pursuant to the Congressional Budget Reconciliation Act of
2006, practitioners are required to bill/report injectable drugs administered in offices and outpatient facilities using the manufacturers’ 11-digit National Drug Code (NDC) numbers1 with the preceding N4 qualifiers and/or HCPCS/CPT codes.
NOTE: The N4 qualifier preceding the NDC number is ONLY required when submitting paper and 837 (X12N) claim transactions. The N4 qualifier is NOT required when submitting electronic claims via Web or PES transactions.
Example of paper claim submission:

Clarified 07/10

Hospitals, dialysis facilities, and Federally Qualified Health Centers (FQHC) billing injectable drugs administered in outpatient facilities must submit claims using both, the NDC numbers (FL 43) and the HCPCS/CPT codes (Fl 44) when submitting electronically or in hardcopy on the UB Claim form.

Providers are required to bill/report the NDC number printed on the drug's package, which
Clarified 01/08
Rev. 12/09

can also be found in the package insert, that was used for each administration and claim or batch of claims submitted. Failure to do so may result in billing an invalid or obsolete NDC number and a subsequent denial of the claim. Claims submitted with invalid NDC numbers are not eligible for rebates and are subject to recoupment by the Department unless the provider resubmits with the NDCs that were used on the DOS, during the procedure.
Claims for injectable drugs received for processing without the NDC numbers and/or
HCPCS/CPT codes or with conflicting or invalid numbers or codes will result in denials.
The HCPCS to NDC cross walk is updated and published quarterly by the Centers for
Medicare and Medicaid (CMS). The crosswalk is accessible via the CMS website and by clicking on the direct link below:

The National Drug Code (NDC) is an 11-digit number, assigned by the manufacturer and is clearly labeled on the drug’s packaging (ex. 99999-9999-99). The first five
(5) digits represent the manufacturer; the second four (4) digits represent the drug’s strength and dosage form; and the last two digits represent the package size and coding. NDC numbers not reported in the 11-digit format previously outlined, will require a preceding zero to be added to the missing number field:
Example 1 – NDC listed as 99999-999-99 should be billed as 99999-0999-99
Example 2 – NDC listed as 9999-9999-99 should be billed as 09999-9999-99
1

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http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/02_aspfiles.asp#TopOfPage
Note: Not all drugs listed on the CMS crosswalk are eligible for reimbursement by
Georgia Medicaid. For specific drugs approved for reimbursement by Georgia Medicaid, refer to the list of drugs contained in this manual.
903.1 General Claims Submission Policy for Ordering, Prescribing, or Referring (OPR)
Providers
CMS expanded the claim editing requirements in Section 1833(q) of the Social
Security Act and the providers’ definitions in sections 1861-r and 1842(b)(18)C. The
Affordable Care Act (ACA) requires physicians or other eligible providers to be enrolled in the GA Medicaid Program to order, prescribe and refer items or services for
Medicaid beneficiaries. Physicians or other eligible providers who are already enrolled in Medicaid as billing providers are not required to enroll separately as Ordering,
Prescribing, or Referring (OPR) providers. Enrollment of these providers will begin on
April 1, 2013.
Beginning July 1, 2013, if the National Provider Identifier (NPI) of the ordering, prescribing, or referring (OPR) provider noted on the GA Medicaid claim is associated with a provider who is not enrolled in the Georgia Medicaid program, the claim will not be paid. Furthermore, the NPI of the provider ordering, prescribing or referring the member for the service rendered must be included on the claim submitted by the rendering provider. Providers who do not have NPIs and who are not authorized to enroll as Medicaid or CHIP providers (i.e. medical residents at hospitals) must apply the NPI of the supervising physician to the claim.

903.2 Non-Rebatable Injectable Drugs
Effective January 14, 2008, the Department no longer provides reimbursement for nonrebateable injectable drugs administered in physicians’ offices or in outpatient settings.

Rev. 01/08

This action is pursuant to the Deficit Reduction Act (DRA) and in accordance with the
Social Security Act—Section 1927. [42 U.S.C. 1396r–8] (a), Requirement for Rebate
Agreement, which cites, ―In order for payment to be available under section 1903(a) or under part B of title XVIII for covered outpatient drugs of a manufacturer, the manufacturer must have entered into and have in effect a rebate agreement described in subsection (b)…‖ Section 1903(a) is applicable to all outpatient drugs, except for certain injectable drugs where the State has authorization from the Federal government though the State Plan for medical assistance. These exceptions include but may not be limited to vaccines, injectable vitamins, etc.
Click on this link for the list of rebateable drugs on the CMS website:

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Benefits/Prescription-Drugs/Medicaid-Drug-Rebate-Program-Data.html then click on: rebate drug product data file [ZIP]
904

Limitations:

Physicians’ Injectable Drug List (PIDL) – October 2013

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The services or groups of services in this Section are covered with limitations. If a physician has special medical justification for exceeding a service limitation, the medical justification should be well documented and made available to the Division upon request.
Such documentation may be requested in a pre-payment or post payment review, and lack of appropriate medical justification will be grounds for the denial, reduction or recoupment of reimbursement. 904.1 Immunizations and Vaccines
Rev. 10/05
Clarified 01/11
Clarified 01/07

The immunizations and vaccines listed in this manual are reported using valid CPT codes. For members less than 19 years of age they are provided through the Health
Check for Kids Program in conjunction with Vaccines for Children (VFC) and indicated by an asterisk [*]. For members 19-21 years of age, coverage is through the
Physician Services Program. For further clarification on specific CPT immunization codes covered under the Health Check program, refer to the Health Check Services
Manual, Appendix E and the Physician Services Manual, Appendix B and B1.

904.1a Administration:
Clarified 01/07

Reimbursement for immunizations and vaccines supplied by VFC and administered to children birth to 18 years and 11 months of age under the
Health Check Program, covers the administration fee only.

904.2

Vitamins
a)

Vitamin B-12 injections are covered only for treatment of pernicious anemia and mal-absorption syndrome.

b)

Other vitamin injectables are not covered unless the provider submits documentation of medical necessity. These injections should not be billed if the patient can tolerate oral medication.

904.3 Hormones
a)

Hormone injections will not be reimbursed more frequently than once monthly. b)

Reimbursement for ACTH is limited to treatment of pituitary insufficiency, ulcerative colitis or infantile spasms, unless documentation of medical necessity is submitted.

c)

Gonadotropin injections for obesity are non-covered.

904.4 Experimental Drugs/Unlabeled Use
Experimental drugs or non-experimental drugs when used as an experimental treatment modality are non-covered. Drugs used for unlabeled purposes are noncovered and shall not be billed to the department.
Investigational or experimental services, drugs, or procedures not covered by Georgia
Medicaid include:

Physicians’ Injectable Drug List (PIDL) – October 2013

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The investigational item or service, itself unless otherwise covered outside of the CLINICAL TRIAL;
Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct CLINICAL management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan); and
Items and services customarily provided by the research sponsors free of charge for any enrollee in the TRIAL.
The cost, however, of routine care and services that are otherwise generally available to Medicaid members, (i.e., there exists a benefit category that is not statutorily excluded) include:
Items or services that are typically provided absent a CLINICAL TRIAL
(e.g., conventional care);
Items or services required solely for the provision of the investigational item or service (e.g., administration of a non-covered chemotherapeutic agent), the
CLINICALLY appropriate monitoring of the effects of the item or service, or the prevention of complications; and
Items or services needed for reasonable and necessary care arising from the provision of an investigational item or service-in particular, for the diagnosis or treatment of complications.
904.5 Other Limitations
Claims for the following types of injections must adhere to the specific limitations as described in this policy to obtain reimbursement:
a)

Antipyretic injections, except for treatment of febrile convulsions of children or malignant diseases when fever cannot be controlled by any other means, are non-covered, unless sufficient documentation of medical necessity is provided b)

Bronchodilators, antihistamine, and decongestant injectables will only be reimbursed for the initial doses when the member is in the acute stage of illness or he is unable to take oral medication (e.g., asthma).

c)

Steroid injections will not be reimbursed more frequently than once monthly for chronic conditions (e.g., arthritis). Up to four (4) injections per month will be reimbursable for acute conditions (e.g., asthma, Herpes Zoster).

d)

Antibiotic injections warranted by diagnosis will be reimbursed for the initial injection and two (2) additional injections when given on successive days
(e.g., pneumonia).

e)

Analgesic injections should be billed only as the initial dosage for acute conditions (e.g., acute myocardial infarction).

Physicians’ Injectable Drug List (PIDL) – October 2013

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CHAPTER 1000
BASIS FOR REIMBURSEMENT

1001
Rev. 09/09

Reimbursement Methodology
Effective September 1, 2009, the Department of Community Health amended the maximum allowable reimbursement for approved drugs on the Physicians’ Injectable
Drug List (PIDL) to the lesser of:
a)
b)

Average Sales Price (ASP) plus 6% as defined January 1st of each year or the
ASP + 6 % upon the drug’s initial availability in the marketplace whichever is later; or

c)

Rev. 01/07

The provider’s usual and customary charge

Average Wholesale Price (AWP) minus 11% for injectable drugs that do not have ASP pricing, until such time that ASP plus 6% pricing becomes available.
Drugs on the PIDL that are priced without an ASP rate are denoted by an inverted triangle [▼].

Only the administration fee, indicated by an asterisk [*]is reimbursable for vaccines and immunizations supplied through the Vaccine for Children’s (VFC) Program or the
Federal Government. These products are supplied at no charge to providers The vaccine administration fee for adults over 19 years of age is covered when the drug is provided by the Federal Government free of charge to the provider.

Rev.10/09

1002

Review and Record Keeping Requirements
The Department will continuously review injectable drug claims. Periodically, a random selection sample of claims will be thoroughly reviewed. In these cases, if questionable, we will request that providers send us documentation supporting the specific services billed to the Department. Therefore, we must require that all supporting documentation, including a copy of the claim, be maintained for the length of time specified in the Part I
Policies and Procedures for Medicaid/PeachCare for Kids manual.

1003
Rev. 01/08

Non-Covered Injectable Drugs and Services:
Drugs and services not covered through the Physician Services Program include, but may not be limited to, those that are:
1. not DCH-approved or not currently listed on the PIDL
2. not FDA approved
3. experimental or investigational
4. used for off-labeled indications
5. not rebatable—except as indicated in Section 1927. [42 U.S.C. 1396r–8] of the Social
Security Act
6. dispensed by and through an outpatient pharmacy

Physicians’ Injectable Drug List (PIDL) – October 2013

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Rev. 01/09
Rev. 06/08

7. self-administered, except if included on the PIDL
8. obsolete or invalid, as indicated by the manufacturer’s NDC number
9. Unclassified or NOC HCPCS/CPT codes used to bill injectable drugs; unless otherwise indicated for temporary use to report newly approved injectable drugs— not yet assigned a unique HCPCS number by CMS. The Unclassified HCPCS codes must be billed/reported in conjunction with the corresponding unique/valid NDC number—no exceptions

Physicians’ Injectable Drug List (PIDL) – October 2013

X-2

Schedule of Maximum Allowable
HCPCS
/CPT
90371
90375
90378
90585
90586
90632
90633
90634
90636
90636
90645
90647
90647
90648
90648
90649
90649
90654
90655
90655
90656
90656
90657
90658
90669
90670
90675

HCPCS/CPT Name, Description, Dose

Brand Name

Hepatitis B Immune Globulin (HBIg), Human, for IM use
Rabies Immune Globulin, IM or s-q Use 150IU
Respiratory Syncytial Virus Immune Globulin (RSV-IgIM),
Palivizumab for intramuscular use, 50 mg, each PA [▼]
Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use 50mg
Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use

HBIg
Bayrab
Synagis

Hepatitis A Vaccine, Adult
Hepatitis A Vaccine, Pediatric/Adolescent 2 Dose* [Drug Supplied by VFC/Health Check]
Hepatitis A Vaccine, Pediatric/Adolescent 3 Dose [▼]

Max Allow
$104.73
$206.47
$1,396.26

Max
Units
1
12
5

Last
Revised
01/2013
01/2013
07/2013

Tice BCG

$120.87

1

01/2013

Theracys

$120.87

6

01/2013

Havrix
Vaqta

$50.93
$8.00

1
1

01/2013
09/2009

Vaqta

$32.30

1

01/2011

Hepatitis A and Hepatitis B Vaccine (HepA-HepB), Adult Dosage
Hepatitis A and Hepatitis B Vaccine (HepA-HepB), Adult Dosage
[▼]
Hemophilus Influenza B Vaccine (Hib), HbOC conjugate (4 dose schedule.), for IM use [▼]
Hemophilus Influenza B Vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for IM use* [Drug Supplied by VFC/Health
Check]
Hemophilus Influenza B Vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for IM use [▼]
Hemophilus Influenza B Vaccine (Hib), PRP-T conjugate (4 dose schedule), for IM use* [Drug Supplied by VFC/Health Check]
Hemophilus Influenza B Vaccine (Hib), PRP-T conjugate (4 dose schedule), for IM use [▼]
Human Papilloma Virus (HPV) vaccine types 6, 11, 16, 18
(quadrivalent), 3 dose schedule for IM use* [Drug Supplied by
VFC/Health Check]
Human Papilloma Virus (HPV) vaccine types 6, 11, 16, 18
(quadrivalent), 3 dose schedule for IM use [ ▼]
Influenza Virus Vaccine, intradermal
Influenza (preservative free)* [Drug Supplied by VFC/Health
Check]
Influenza (preservative free)*
Influenza Virus Vaccine, Split virus, preservative free, for individuals 3 yrs and older, for intramuscular use* [Drug Supplied by VFC/Health Check]
Influenza Virus Vaccine, Split virus, preservative free, for individuals 3 yrs and older, for intramuscular use
Influenza Virus Vaccine, split virus, for children 6-35 months of age, for IM use* [Drug Supplied by VFC/Health Check]

Twinrix
Twinrix

$10.00
$95.69

1
1

01/2010
01/2010

Pedvax HIB

$24.18

1

01/2011

Pedvax HIB

$8.00

1

09/2009

Pedvax HIB

$24.18

1

01/2011

Hiberix

$8.00

1

01/2010

Hiberix

$24.25

1

01/2011

Gardasil

$8.00

1

01/2010

Gardasil

$144.53

1

01/2013

Fluzone
Fluzone pediatric

$18.98
$8.00

1
1

01/2013
10/2003

Fluzone pediatric

$16.46
$8.00

1
1

01/2013
01/2010

$12.40

1

01/2013

Fluzone

$8.00

1

04/2003

Influenza Virus Vaccine, Whole Virion (>3 yrs)* [Drug Supplied by VFC/Health Check]
Pneumococcal Conjugate Vaccine, polyvalent, for children under
5 years, for intramuscular use* [Drug Supplied by VFC/Health
Check]
Pneumococcal Conjugate 13 Valent, for IM use [Drug Supplied by VFC/Health Check]
Rabies Vaccine for IM Use

Flu Vaccine

$8.00

1

09/2009

Prevnar

$8.00

1

01/2001

Prevnar 13

$8.00

1

07/2010

$190.40

1

01/2013

Flu Vaccine
Flu Vaccine

Rabavert

Physicians’ Injectable Drug List (PIDL) – October 2013

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Schedule of Maximum Allowable
HCPCS
/CPT
90680
90698

90700
90702
90707
90707
90710
90713
90713
90714
90715
90716
90716
90723

90732
90732
90733
90734
90735
90736
90740
90744
90746
90747
90748
C9257

HCPCS/CPT Name, Description, Dose

Brand Name

Rotavirus Vaccine, pentavalent, 3 dose schedule, live, for oral use* [Drug Supplied by VFC/Health Check]
Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine,
Haemophilus Influenza Tyoe B, and Poliovirus vaccine, inactivated (DTAP-HB-IPB), for IM use* [Drug Supplied by
VFC/Health Check]
Diphtheria, Tetanus Toxoids, and Acellular Pertussis Vaccine
(DTaP), for use in individuals younger than 7 years, IM use* [Drug
Supplied by VFC/Health Check].
Diphtheria and Tetanus Toxoids (DT) adsorbed for use in individuals younger than 7 years, for intramuscular use [Health
Check] [▼]
Measles, Mumps and Rubella Virus Vaccine, Live* [Drug
Supplied by VFC/Health Check]
Measles, Mumps and Rubella Virus Vaccine, Live [▼]
Measles, Mumps, Rubella, and Varicella Vaccine (MMRV), live, for subcutaneous use* [Drug Supplied by VFC/Health Check]
Poliovirus Vaccine, inactivated (IPV) for SQ use* [Drug Supplied by VFC/Health Check]
Poliovirus Vaccine, inactivated (IPV) for SQ use [▼]
Tetanus and Diphtheria Toxoids (Td) absorbed, preservative free, for use in seven years or older* [Drug Supplied by VFC/Health
Check]
Tetanus, Diphtheria Toxoids and Acellular Pertussis Vaccine
(TdaP), for use in individuals 7 years or older, for intramuscular use* [Drug Supplied by VFC/Health Check]
Varicella Virus Vaccine, Live, for s-q use* [Drug Supplied by
VFC/Health Check]
Varicella Virus Vaccine, Live, for s-q use [▼]
Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine,
Hepatitis B, and Poliovirus Vaccine, inactivated (DtaP-HepB-IPV), for IM use* [Drug Supplied by VFC/Health Check]

Rotavirus

$8.00

Max
Units
1

Pentacel

$10.00

1

01/2010

Infanrix, Tripedia, Daptacel

$10.00

1

02/1994

DIP/TET ped inj

$39.16

1

01/2013

M-M-R II Vaccine w/ Diluent

$10.00

1

09/2009

M-M-R II Vaccine w/ Diluent
MMRV

$57.34
$10.00

1
1

01/2013
08/2006

IPOL

$8.00

1

01/2009

IPOL
Td

$29.16
$10.00

1
1

01/2013
07/2005

TdaP

$10.00

1

10/2005

Varivax

$8.00

1

04/2008

Varivax
Pediarix

$96.57
$10.00

1
1

01/2013
01/2009

Pneumococcal Vaccine, 23-Valent* [Drug Supplied by
VFC/Health Check]
Pneumococcal Vaccine, 23-Valent
Meningococcal Polysaccharide Vaccine for(any group(s) SQ Use
Meningococcal Conjugate Vaccine, Serogroups A, C, Y, and W135 (tetravalent) for IM use [▼]
Japanese Encephalitis Virus Vaccine for s-q use
Zoster (shingles) , live, for SQ injections, 0.65 ml ( > age 60) [▼]
Hepatitis B Vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use 40mcg
Hepatitis B Vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use* [Drug Supplied by VFC/Health
Check]
Hepatitis B Vaccine, adult dosage, for intramuscular use 20mcg
Hepatitis B Vaccine, dialysis or immunosuppresed patient dose (4 dose schedule), for intramuscular use 40mcg
Hepatitis B and Hemophilus Influenza B Vaccine (HepB-Hib) for intramuscular use* [Drug Supplied by VFC/Health Check]
Bevacizumab injection (ophthalmic use / 0.25mg) 10mg

Pneumovax 23

$8.00

1

09/2009

Pneumovax 23
Menomune A/C/Y/W-135
Menactra, Menveo

$65.77
$106.49
$113.60

1
1
1

01/2013
01/2012
01/2013

Je-Vax
Zostavax
Recombivax HB 3-Dose

$102.08
$170.15
$119.42

1
1
1

09/2009
01/2013
09/2009

Engerix-B 10mcg/0.5ml

$8.00

1

09/2009

$59.71
$119.42

1
1

09/2009
09/2009

Comvax

$10.00

1

07/2009

Avastin

$63.45

1

01/2013

Recombivax HB
Engerix-B 40mcg/1ml

Physicians’ Injectable Drug List (PIDL) – October 2013

Max Allow

Last
Revised
08/2006

A-2

Schedule of Maximum Allowable
HCPCS
/CPT
C9292
C9295
C9296
C9298
C9313
J0129
J0133
J0150
J0152

HCPCS/CPT Name, Description, Dose

Brand Name

Pertuzumab 10mg PA
Carfilzomib 1mg PA
Ziv-Aflibercept 1mg PA
Ocriplasmin 0.125mg [ ▼] ado-trastuzumab emtansine 1mg PA [ ▼]
Abatacept 10 mg, PA
Acyclovir 5mg
Adenosine (for therapeutic use) 6mg
Adenosine (for diagnostic use) 30mg

Perjeta
Kyprolis
Zaltrap
Jetrea
Kadcyla
Orencia
Zovirax
Adenocard
Adenoscan

J0171
J0178
J0180
J0207
J0220
J0256

Adrenaline, Epinephrine HCl 0.1mg
Aflibercept (ophthalmic use) 1mg PA
Agalsidase Beta 1mg
Amifostine 500mg
Alglucosidase Alfa 10mg
Alpha-1 Proteinase Inhibitor, Human, 10 mg

J0278
J0280
J0285
J0290
J0295
J0300
J0360
J0461
J0475
J0490
J0500
J0515
J0558

Amikacin Sulfate, 100 mg
Aminophyllin, 250 mg
Amphotericin B 50 mg
Ampicillin 500 mg
Ampicillin sodium/sulbactam sodium 1.5 g
Amobarbital Sodium 125 mg [ ▼]
Hydralazine HCl, 20 mg
Atropine Sulfate, 0.01mg
Baclofen 10 mg
Belimumab 10mg PA
Dicyclomine HCl up to 20mg
Benzotropine Mesylate 1 mg
Penicillin G Benzathine, Penicillin G Procaine 100,000units

J0561
J0585
J0586
J0587
J0588
J0595
J0598
J0610
J0640
J0641
J0670
J0690
J0694
J0696
J0697
J0698
J0702

Penicillin G Benzathine 100,000units
OnabotulinumtoxinA, per 1 U
Abobotulinumtoxin A 5U
RimabotulinumtoxinB per 100 U
Incobotulinumtoxin A 1U
Butorphanol Tartrate 1 mg
C-1 esterase Inhibitor 10 units (Human) Cinryze PA
Calcium gluconate per 10 mg
Leucovorin Calcium 50 mg
Leucovorin calcium 0.5mg
Mepivacaine HCl Vial 10 ml
Cefazolin Sodium 500 mg
Cefoxitin Sodium, 1 g
Ceftriaxone Sodium, 250 mg
Cefuroxime Sodium, 750 mg
Cefotaxime Sodium, 1 g
Betamethasone Acetate-Betamethasone Sodium Phosphate, 3mg

$102.33
$29.29
$15.57
$1054.65
$29.61
$22.40
$0.03
$7.14
$109.01

Max
Units
84
60
400
2
360
100
200
4
3

Last
Revised
01/2013
04/2013
04/2013
04/2013
07/2013
01/2013
01/2010
01/2013
01/2013

Adrenalin
Eylea
Fabrazyme
Ethyol
Myozyme
Prolastin

$0.06
$980.50
$140.68
$306.16
$206.03
$3.95

5
4
100
4
120
480

01/2013
01/2013
01/2013
01/2013
01/2013
01/2013

Amikin
Aminophylline
Amphocin, Fungizone
Ampicillin Sodium
Unasyn
Amytal
Apresoline
Atropine Sulfate
Lioresal
Benlysta
Bentyl
Cogentin
Bicillin CR, Bicillin CR
900/300,
Penicillin G Benzathine
Botox
Dysport
Myobloc
Xeomin
Stadol
Cinryze
Calcium Gluconate
Leucovorin Calcium
Fusilev
Carbocaine
Ancef, Kefzol
Mefoxin
Rocephin
Zinacef
Claforan
Celestone Soluspan

$0.93
$0.72
$17.81
$1.69
$2.30
$153.58
$3.18
$0.02
$175.88
$38.27
$33.25
$25.70
$3.78

15
10
3
4
2
8
15
330
8
100
2
6
24

01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2011
01/2013
01/2013
01/2013
01/2013
01/2013

$4.74
$5.47
$6.90
$10.89
$4.46
$1.05
$47.19
$0.70
$2.71
$1.85
$1.12
$0.75
$5.60
$0.73
$3.02
$1.76
$5.57

24
600
200
100
300
4
100
20
30
800
40
8
3
8
4
2
4

01/2013
01/2013
01/2013
01/2013
01/2013
01/2012
01/2013
01/2013
01/2013
02/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013

Physicians’ Injectable Drug List (PIDL) – October 2013

Max Allow

A-3

Schedule of Maximum Allowable
HCPCS
/CPT
J0725
J0743
J0745
J0775
J0780
J0795
J0878
J0881
J0885
J0894
J0895
J0897
J0897
J1000
J1020
J1030
J1040
J1050
J1070
J1080
J1100
J1110
J1120
J1160
J1165
J1170
J1190
J1200
J1245
J1250
J1260
J1290
J1300
J1335
J1364
J1410
J1440
J1441
J1450
J1453
J1458
J1459
J1561

HCPCS/CPT Name, Description, Dose
Gonadotropin, Chorionic, per 1000 USP units
Imipenem and Cilastatin, 250mg
Codeine Phosphate 30 mg
Collagenase Clostridium Histolyticum 0.01mg
Prochlorperazine 10 mg
Corticoreline Ovine Triflutate, 1 microgram
Daptomycin ( Cubicin), 1mg
Darbepoetin Alfa, 1 microgram (non-ESRD use)
Epoetin Alfa, (for non-ESRD use), 1000 units
Decitabine 1mg
Deferoxamine Mesylate 500 mg
Denosumab 1mg PA
Denosumab 1mg
Deopo-estradiol Cypionate 5 mg
Methylprednisolone Acetate 20 mg
Methylprenisolone Acetate 40 mg
Methylprenisolone Acetate 80 mg
Medroxyprogesterone Acetate, 1 mg
Testosterone Cypionate 100 mg
Testosterone Cypionate 200 mg
Dexamethasone Sodium Phosphate, 1 mg
Dihydroergotamine Mesylate 1 mg
Acetazolamide 500 mg
Digoxin 0.5 mg
Phenytoin Sodium 50 mg
Hydromorphone HCl, 4 mg
Dexrazoxane HCl 250 mg
Diphenhydramine HCl 50 mg
Dipyridamole 10 mg
Dobutamine HCl per 250 mg
Dolasetron Mesylate 10 mg
Ecallantide 1mg
Eculizumab, 10 mg PA
Ertapenem, (Invantz), 500 mg
Erythromycin Lactobionate, 500 mg
Estrogen Conjugated, 25 mg
Filgrastim (G-CSF) 300 mcg
Filgrastim (G-CSF) 480 mcg/vial
Fluconazole 200 mg
Fosaprepitant dimeglumine, for injection, 1 mg
Galsufase for Injection, 1 mg PA
Immune Globulin IV, (Human) nonlyophilized liquid 500mg
Immune Globulin IV, (Human) nonlyophilized liquid 500mg

J1566
J1569
J1570
J1572
J1580

Immune Globulin, IV, Lyophilized (e.g., powder), 500 mg
Immune Globulin IV, (Human) nonlyophilized liquid 500mg
Ganciclovir sodium, 500 mg
Immune Globulin IV, (Human) nonlyophilized liquid 500mg
Garamycin, Gentamycin 80 mg

Brand Name
Profasi HP; Pregnyl
Primaxin
Codeine Phosphate
Xiaflex
Compazine
Acthrel
Cubicin
Aranesp
Procrit
Dacogen
Desferal
Prolia
Xgeva
Depogen
Depo-Medrol
Edrol-40
Edrol-80
Depo-Provera
Depo-Testosterone
Depo-Testosterone
Decajet, Dexone, Solurex
D.H.E. 45
Diamox
Lanoxin
Dilantin
Dilaudid
Zinecard
Benadryl
Persantine
Dobutrex
Anzemet
Kalbitor
Soliris
Invanz
Erythromycin Lactobionate
Premarin
Neupogen
Neupogen
Diflucan in Saline
Emend
Naglazyme
Privigen
Gamunex/Gamunex C,
Gammaked
Immune Globulin
Gammagard liquid
Cytovene
Flebogamma Dif
Gentamycin

Physicians’ Injectable Drug List (PIDL) – October 2013

Max Allow
$12.64
$7.75
$1.35
$37.51
$1.40
$5.82
$0.57
$3.45
$10.26
$34.05
$8.24
$14.27
$14.27
$7.40
$3.11
$2.89
$5.60
$0.20
$5.07
$5.78
$0.10
$39.31
$28.40
$1.35
$0.33
$1.61
$165.93
$0.84
$0.95
$5.44
$7.54
$319.61
$199.36
$31.54
$10.60
$139.45
$275.69
$435.92
$4.29
$1.73
$355.52
$35.57
$38.23

Max
Units
10
4
4
90
40
80
600
500
60
50
4
60
120
1
6
3
2
1000
4
2
50
4
4
2
40
1
8
4
6
2
10
30
90
2
2
1
3
2
3
150
50
200
200

Last
Revised
01/2013
01/2013
01/2011
01/2011
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013

$34.74
$37.64
$72.47
$34.95
$1.04

180
120
1
120
7

01/2013
01/2013
01/2013
01/2013
01/2013

A-4

Schedule of Maximum Allowable
HCPCS
/CPT
J1600
J1610
J1626
J1630
J1631
J1642
J1644
J1670
J1720
J1725
J1743
J1745
J1750
J1756
J1790
J1800
J1815
J1840
J1885
J1940
J1950
J1955
J1980
J2001
J2010
J2020
J2150
J2175
J2185
J2210
J2250
J2260
J2275
J2300
J2310
J2323
J2353
J2354
J2355
J2357
J2360
J2370
J2405
J2410
J2469
J2501
J2505
J2507
J2510

HCPCS/CPT Name, Description, Dose
Gold Sodium Thiomalate up to 50 mg
Glucagon 1 mg
Granisetron HCl, 100 mcg
Haloperidol, 5 mg
Haloperidol Deconate 50 mg
Heparin Lock Flush 10 U/ml
Heparin Sodium 1000 U
Tetanus Immune Globulin 250 U
Hydrocortisone Sodium Succinate, 100 mg
Hydroxyprogesterone Caproate 1mg PA [ ▼]
Idursulfase 1 mg, IV injection PA
Infliximab 10 mg PA
Iron Dextran Inj, 50mg
Iron Sucrose Complex, 1 mg
Droperidol 5 mg
Propranolol HCl 1 mg
Insulin per 5 U
Kanamycin 500 mg
Ketorolac Tromethamine 15 mg
Furosemide up to 20 mg
Leuprolide Acetate (for Depot Suspension) 3.75 mg
Levocarnitine, 1 g
Hyoscyamine Sulfate up to 0.25 mg
Lidocaine HCl, 10 mg
Lincomycin HCl, 300 mg
Linezolid, 200 mg
Mannitol 25% in 50 ml
Meperidine 100 mg
Meropenem 100mg
Methylergonovine Maleate 0.2 mg
Midazolam HCl 1 mg
Milrinone Lactate
Morphine Sulfate 10 mg
Nalbuphine HCl, 10 mg
Naloxone HCl, 1 mg
Natalizumab, 1 mg PA
Octreotide, Depot for IM use
Octreotide, non-depot form, SQ or IV Injection, 25 mcg
Oprelvekin, 5 mg
Omalizumab 5mg PA
Orphenadrine Citrate 60 mg
Phenylephrine HCl 1 ml
Ondansetron HCl per 1 mg
Oxymorphone HCl 1 mg
Palonosetron HCL, Injection 25 mcg
Paricalcitol 1 mcg
Pegfilgrastim 6 mg
Pegloticase 1mg PA
Penicillin G Procaine, Aqueous, up to 600,000 U

Brand Name
Myochrysine
Glucagon
Kytril
Haldol
Haloperidol Deconate
Heparin Lock Flush
Heparin Sodium
Baytet
Solu-Cortef
Makena
Elaprase
Remicade
INFeD
Venofer
Inapsine
Inderal
Insulins
Kantrex
Toradol
Lasix
Lupron Depot
Carnitor
Levsin
Xylocaine HCl
Lincocin
Zyvox
Mannitol
Demerol
Merrem
Methergine
Versed
Primacor
Morphine Sulfate Inj
Nubain
Narcan
Tysabri
Sandostatin LAR
Sandostatin
Neumega
Xolair
Norflex
Neo-Synephrine
Zofran
Numorphan
Aloxi
Zemplar
Neulasta
Krystexxa
Wycillin Tubex

Physicians’ Injectable Drug List (PIDL) – October 2013

Max Allow
$25.04
$118.18
$0.63
$2.11
$19.16
$0.17
$0.20
$278.27
$4.39
$736.92
$455.03
$66.41
$11.97
$0.28
$3.29
$3.73
$0.53
$7.69
$0.29
$2.13
$672.89
$6.29
$16.04
$0.02
$7.39
$38.95
$1.90
$2.07
$1.36
$4.03
$0.18
$2.68
$4.31
$0.97
$12.18
$12.30
$129.66
$1.41
$262.88
$23.54
$6.62
$1.15
$0.17
$2.32
$18.98
$1.80
$2,921.12
$356.54
$13.52

Max
Units
3
2
20
5
9
2
40
4
20
250
45
100
100
500
4
4
2
4
8
8
24
5
50
7
3
16
2
20
4
28
23
10
20
2
300
30
20
1
75
4
5
32
4
10
20
1
8
4

Last
Revised
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
04/2013
01/2010
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2010
01/2013
01/2013
01/2013
01/2013
01/2013
09/2009
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013

A-5

Schedule of Maximum Allowable
HCPCS
/CPT
J2515
J2540
J2543
J2550
J2560
J2562
J2675
J2680
J2690
J2700
J2710
J2720
J2778
J2785
J2790
J2792

HCPCS/CPT Name, Description, Dose

Brand Name

Max Allow
$33.02
$0.60
$2.98
$1.63
$13.95
$291.39
$1.56
$15.37
$13.66
$2.26
$0.43
$0.77
$398.01
$53.64
$84.45
$18.33

Max
Units
4
2
4
2
2
24
2
5
1
8
4
5
5
4
15
250

Last
Revised
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013

Nembutal Sodium
Pfizerpen, Pen G K+
Zosyn
Phenergan
Phenobarbital
Mozobil
Progesterone
Prolixin
Procainamide
Bactocill
Prostigmin
Protamine Sulfate
Lucentis
Lexiscan
WinRho-D
WinRho SDF

J2794
J2796
J2800
J2820
J2916
J2920

Pentobarbital Sodium 50 mg
Penicillin G Potassium up to 600,000 U
Piperacill Sodium / Tazobactam Sodium , 1g / 0.125 g
Promethazine HCl 50 mg
Phenobarbital Sodium up to 120 mg
Plerixafor 1 mg PA
Progesterone, per 50 mg
Fluphenazine Deconate 25 mg
Procainamide, up to 1 g
Oxacillin Sodium up to 250 mg
Neostigmine Methylsulfate up to 0.5 mg [ ▼]
Protamine Sulfate, 10 mg
Ranibizumab 0.1 mg, intravitreal injection (per eye) PA
Regadenoson 0.1mg
Rho D Immune Globulin, Human, Full Dose, 300 mcg
Injection, Rho D immune globulin, intravenous, human solvent detergent, 100 IU
Risperidone, long acting, 0.5 mg PA
Romiplostim 10mcg PA
Methocarbamol up to 10 ml
Sargramostim 50 mcg
Sodium Ferric Gluconate Complex / Sucrose, 12.5 mg
Methylprenisolone Sodium Succinate 40 mg

Risperdal Consta
Nplate
Robaxin
Leukine
Ferrlecit
Solu-Medrol

$5.64
$49.32
$36.43
$29.69
$3.10
$1.63

100
100
3
17
5
60

01/2013
01/2013
01/2013
01/2013
01/2013
01/2013

J2930
J2941

Methylprenisolone Sodium Succinate 125 mg
Somatropin 1 mg [ ▼]

$2.60
$80.03

20
4

01/2013
01/2013

J3000
J3030
J3070
J3105
J3130
J3230
J3240
J3250
J3260
J3262
J3301
J3303
J3315
J3357
J3360
J3370
J3385
J3396
J3410
J3420
J3430
J3475
J3480
J3486

Streptomycin HCl, 1 g
Sumatriptan Succinate, 6 mg/vial [ ▼]
Pentazocine Lactate 30 mg
Terbutaline Sulfate 1 mg
Testosterone Enanthate 200 mg
Chlorpromazine HCl 50 mg
Thyrotropin Alpha 1.1 mg
Trimethobenzamide, up to 200 mg
Tobramycin Sulfate up to 80 mg
Tocilizumab 1mg PA
Triamcinolone Acetonide 10 mg
Triamcinolone Hexacetonide per 5 mg
Triptorelin Pamoate, injection, 3.75 mg
Ustekinumab 1mg, PA
Diazepam 5 mg
Vancomycin 500 mg Vial
Velaglucerase Alfa 100u
Verteporfin, 0.1 mg
Hydroxyzine HCl 25 mg
Vitamin B-12, cyanocabalamin, up to 1000 mcg
Phytonadione (Vitamin K), per 1 mg
Magnesium Sulfate per 500 mg
Potassium Chloride, 2 mEq
Ziprasidone Mesylate 10mg

Solu-Medrol
Humatrope, Genotropin
Nutropin
Streptomycin Sulfate
Imitrex
Talwin
Brethine
Delatestryl
Chlorpromazine HCl
Thyrogen
Tigan
Nebcin
Actemra
Kenalog 10
Aristospan
Trelstar Depot/LA
Stelara
Valium
Vancocin
VPRIV
Visudyne
Vistaril
Vitamin B-12
Aqua-Mephyton
Magnesium Sulfate 50%
Potassium Chloride
Geodon

$15.07
$52.33
$24.50
$3.81
$9.26
$17.86
$1,051.90
$10.38
$2.55
$3.56
$1.80
$1.82
$175.79
$134.00
$3.34
$2.42
$348.86
$10.28
$1.31
$0.56
$1.43
$0.15
$0.01
$8.76

2
2
4
2
2
8
1
2
3
800
8
4
6
90
4
4
54
120
5
1
10
12
20
4

01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2012
01/2013
01/2012
01/2013

Physicians’ Injectable Drug List (PIDL) – October 2013

A-6

Schedule of Maximum Allowable
HCPCS
/CPT
J3490
J7030
J7040
J7042
J7050
J7060
J7070
J7100
J7120
J7178
J7300
J7302
J7307
J7312
J7321
J9000
J9010
J9015
J9017
J9019
J9020
J9025
J9027
J9033
J9035
J9040
J9041
J9042
J9043
J9045
J9050
J9055
J9060
J9070
J9098
J9100
J9120
J9130
J9150
J9151
J9155
J9171
J9178
J9179
J9181
J9185

HCPCS/CPT Name, Description, Dose
Potassium Acetate 2meq
Normal Saline Solution, 1000 cc
Normal Saline Solution, 500 cc
Dextrose Normal Saline 5% 500 cc
Normal Saline Solution, 250 cc
Dextrose (D-Glucose) D5W 500 cc
Dextrose (D-Glucose) D5W 1000 cc
Dextran-40 500 cc
Ringers Lactate 1000 cc
Human Fibrinogen concentrate 1mg [ ▼]
Copper IUD [ ▼]
Levonorgestrel Releasing Intrauterine Contraceptive System,
52mg [▼]
Etonogestrel (contraceptive) Implant System, including implant and supplies [▼]
Dexamethasone Intravitreal Implant 0.1mg
Hyaluronan (Sodium Hyaluronate) or derivative, intra-articular Inj, per dose
Doxorubicin 10 mg
Alemtuzumab 10 mg
Aldesleukin, per single use vial
Arsenic Trioxide 1mg
Asparaginase Erwinia Chrysanthem 1,000 IU PA]
Asparaginase, 10,000 U
Azacitidine 1 mg
Clofarabine, 1 mg
Bendamustine, 1mgPA
Bevacizumab, 10 mg
Bleomycin Sulfate, 15 U
Bortezomib, 0.1 mg
Brentuximab Vendotin 1mg PA
Cabazitaxel 1mg PA
Carboplatin, 50 mg
Carmustine, 100 mg/cc
Cetuximab 10 mg
Cisplatin, powder or Solution per 10mg
Cyclophosphamide 100mg
Cytarabine Liposome, 10 mg
Cytarabine 100 mg
Dactinomycin, 0.5 mg
Dacarbazine 100 mg
Daunorubicin HCl, 10 mg
Daunorubicin Citrate Lipo, 10 mg [▼]
Degarelix 1mg
Docetaxel 1mg
Epirubicin HCl Inj. 2 mg
Eribulin Mesylate 0.1mg PA
Etoposide 10 mg inj
Fludarabine Phosphate 50 mg

Brand Name
Potassium Acetate
Sodium Chloride
Sodium Chloride
Dextrose with Na CL
Sodium Chloride
Dextrose in Water
Dextrose in Water
Rheomacrodex in D5
Lactated Ringers
RiaStap
ParaGard IUD
Mirena

$0.03
$1.07
$0.53
$0.49
$0.27
$1.03
$2.05
$21.93
$0.99
$0.97
$638.66
$750.86

Max
Units
20
2
4
4
8
4
5
4
2
7000
1
1

Implanon, Nexplanon

$704.26

1

12/2011

Ozurdex
Hyalgan, Supartz

$195.86
$89.98

7
2

01/2013
01/2013

25
3
4
15
50
10
215
155
240
135
3
28
200
60
40
10
107
50
40
5
80
7
20
11
18
240
500
200
30
30
2

01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
02/2013
01/2013
01/2013
01/2013
01/2013
01/2013

Adriamycin PFS
Campath
Proleukin
Trisenox
Erwinaze
Elspar
Vidaza
Clolar
Treanda
Avastin
Blenoxane
Velcade
Adcetris
Jevtana
Paraplatin
BiCNU
Erbitux
Platinol AQ
Cytoxan
Depocyt
Cytosar-U
Cosmegen
Dtic-Dome
Cerubidine
Daunoxone
Firmagon
Taxotere
Ellence
Halaven
Toposar
Fludara

Physicians’ Injectable Drug List (PIDL) – October 2013

Max Allow

$3.41
$611.45
$1,246.98
$45.13
$334.32
$63.20
$5.53
$126.25
$20.62
$63.45
$21.39
$44.31
$98.99
$137.82
$3.29
$175.75
$51.80
$2.12
$23.37
$528.75
$0.96
$577.60
$3.40
$22.05
$60.52
$2.86
$6.37
$1.58
$95.54
$0.74
$86.66

Last
Revised
07/2012
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
09/2011
10/2010

A-7

Schedule of Maximum Allowable
HCPCS
/CPT
J9190
J9201
J9202
J9206
J9207
J9208
J9209
J9214
J9217
J9225
J9228
J9230
J9250
J9260
J9263
J9264
J9265
J9280
J9293
J9302
J9303
J9305
J9307
J9310
J9328
J9330
J9340
J9351
J9355
J9357
J9360
J9370
J9390
J9395
J9600
P9046
P9047
P9048
Q0090
Q0138
Q2035
Q2036
Q2037
Q2038
Q2049
Q2050

HCPCS/CPT Name, Description, Dose
Fluorouracil 500 mg
Gemcitabine HCl, 200 mg
Goserelin Acetate Implant, per 3.6 mg
Irinotecan HCl, 20 mg
Ixabepilone, 1mg
Ifosfamide, 1 g
Mesna, 200 mg
Interferon, Alfa-2B, Recombinant, 1 million U
Leuprolide Acetate 7.5 mg
Histrelin Implant (Vantas) 50mg PA
Ipilimumab 1mg PA
Mechlorethamine HCl (Nitrogen Mustard) 10 mg
Methotrexate 5 mg
Methotrexate 50 mg
Oxaliplatin, 0.5 mg
Paclitaxel Protein-Bound Particles, 1 mg
Paclitaxel 30 mg
Mitomycin 5 mg
Mitoxantrone, 5 mg
Ofatumumab 10mg PA
Panitumumab, 10 mg
Pemetrexed disodium, 10 mg
Pralatrexate 1mg
Rituximab 100 mg
Temozolamide 1mg PA
Temsirolimus 1mg PA
Thiotepa 15 mg
Topotecan 0.1mg
Trastuzumab 10 mg
Valrubicin 200mg
Vinblastine 1 mg
Vincristine 1 mg
Vinorelbine Tartrate, 10 mg
Fulvestrant 25 mg
Porfimer Sodium, 75 mg [▼]
Albumin 25% in 20 ml (Human)
Albumin 25% in 50 ml (Human)
Plasma Protein Fraction (Human), 5%, 250ML
Levonorgestrel-releasing intrauterine system IUS [▼]
Ferumoxytol 1mg(non-ESRD use) PA
Afluria Vaccine 3 year & >, IM
Influenza virus vaccine, split virus, for 3 years of age and older, IM use Influenza virus vaccine, split virus, for 3 years of age and older, IM use Influenza virus vaccine, split virus, for 3 years of age and older, for
IM use
Injection Doxorubicin HCl, liposomal Imported Lipodos 10mg
Injection Doxorubicin HCl, Liposomal Doxil 10mg

Brand Name
Adrucil
Gemzar
Zoladex
Camptosar
Ixempra
Ifex
Mesnex
Intron A
Eligard
Vantas Implant Kit
Yervoy
Mustargen
Folex
Folex
Eloxatin
Abraxane
Taxol
Mutamycin
Novantrone
Arzerra
Vectibix
Alimta
Folotyn
Rituxan
Temodar
Torisel
Thioplex
Hycamtin
Herceptin
Valstar
Velban
Oncovin
Navelbine
Faslodex
Photofrin
Plasbumin 25
Plasbumin 25
Plasmaprotein fract, 5%,
Skyla
Feraheme
Afluria
Flulaval

Max Allow
$1.82
$10.86
$178.39
$4.70
$66.43
$29.16
$3.60
$19.29
$215.13
$2,981.05
$125.17
$157.86
$0.20
$1.95
$3.95
$9.52
$5.40
$24.04
$36.88
$45.42
$89.20
$58.06
$182.65
$660.78
$4.83
$56.14
$175.48
$3.17
$76.54
$1,038.99
$1.17
$3.78
$11.06
$88.34
$19,869.02
$19.68
$49.20
$41.67
$694.54
$0.64
11.54
$9.83

Max
Units
2
16
3
42
89
10
10
52
6
1
300
3
10
400
560
559
25
8
8
200
82
130
60
60
440
25
5
40
80
4
20
3
10
20
1
10
4
2
1
510
1
1

Last
Revised
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2012
01/2013
01/2013
04/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2013
01/2012
01/2012
01/2012
01/2012
07/2013
01/2013
09/2012
09/2012

Fluvirin

$14.05

1

09/2012

Fluzone

$12.05

1

09/2012

$498.26
$545.44

15
15

07/2012
07/2013

Imported Lipodox inj
Doxil

Physicians’ Injectable Drug List (PIDL) – October 2013

A-8

Schedule of Maximum Allowable
HCPCS
/CPT
Q2051
Q2051
S0020
S0032
S0077
S0166

HCPCS/CPT Name, Description, Dose
Zoledronic Acid (Zometa), 1 mg
Zoledronic Acid ( Reclast), 1 mg PA
Bupivacaine HCl, 30 ml
Nafcillin Sodium 2 g [▼
Clindamycin Phosphate 300 mg
Olanzapine, 2.5 mg

Brand Name
Zometa
Reclast
Marcaine
Nafcillin Sodium
Cleocin
Zyprexa

Physicians’ Injectable Drug List (PIDL) – October 2013

Max Allow
$196.41
$196.41
$2.31
$24.68
$3.24
$8.16

Max
Units
4
5
3
4
4
4

Last
Revised
07/2013
07/2013
01/2013
01/2012
01/2013
01/2013

A-9

Schedule of Maximum Allowable

Physicians’ Injectable Drug List (PIDL) – October 2013

A-10

Schedule of Maximum Allowable
Appendix B

Physicians’ Injectable Drug List (PIDL) Review Request Form
To complete and submit form click here http://dch.georgia.gov/vgn/images/portal/cit_1210/4/19/163530745PIDL%20Review%20RequestFormProvider2010920.pdf \

Physicians’ Injectable Drug List (PIDL) – October 2013

B-1

Schedule of Maximum Allowable
Appendix C

Georgia Families
Georgia Families (GF) is a statewide program designed to deliver health care services to members of Medicaid and PeachCare for Kids®. The program is a partnership between the Department of Community Health (DCH) and private care management organizations (CMOs). By providing a choice of health plans, Georgia Families allows members to select a health care plan that fits their needs.
It is important to note that GF is a full-risk program; this means that the three CMOs licensed in Georgia to participate in GF are responsible and accept full financial risk for providing and authorizing covered services. This also means a greater focus on case and disease management with an emphasis on preventative care to improve individual health outcomes. In addition, each CMO contracts with a behavioral health organization in order to coordinate physical and mental health services for in order to improve member care, coordination, and efficiency.
The three licensed CMOs:
Amerigroup Community Care
800-600-4441
www.myamerigroup.com

Peach State Health Plan
800-704-1484
www.pshpgeorgia.com

WellCare of Georgia
866-765-4385
www.wellcare.com

Children, pregnant women and women with breast or cervical cancer on Medicaid, as well as children enrolled in
PeachCare for Kids® are eligible to participate in Georgia Families. Children in foster care will not be enrolled in
Georgia Families.
Eligibility Categories for Georgia Families:
Included Populations
PeachCare for Kids®
Low-Income Medicaid (LIM)
Right from the Start Medicaid (RSM)
Women’s Health Medicaid (WHM)
Transitional Medicaid
Refugees
Planning for Healthy Babies
Resource Mothers Outreach
Children (Newborn)

Excluded Populations
Foster Care
Aged, Blind and Disabled
Nursing home
Long-term care (Waivers, SOURCE)
Federally Recognized Indian Tribe
Georgia Pediatric Program (GAPP)
Hospice
Community Based Alternative for Youths
(CBAY)
Children’s Medical Services program
Medicare Eligible
Supplemental Security Income (SSI) Medicaid
Medically Needy

Medicaid and PeachCare for Kids® members will continue to be eligible for the same services they receive through traditional Medicaid as well as new services. Members will not have to pay more than they paid for
Medicaid co-payments or PeachCare for Kids® premiums. With a focus on health and wellness, the CMOs will provide members with health education and prevention programs as well as expanded access to plans and
Physicians’ Injectable Drug List (PIDL) – October 2013
C-1

Schedule of Maximum Allowable providers, giving them the tools needed to live healthier lives. Providers participating in Georgia Families will have the added assistance of the CMOs to educate members about accessing care, referrals to specialists, member benefits, and health and wellness education.
Effective February 1, 2012, all three health plans are located state-wide; giving Georgia Families members choices in making important decisions about health care services for themselves.
The Department of Community Health has contracted with three CMOs to provide these services: Amerigroup
Community Care, Peach State Health Plan and WellCare. Members can contact Georgia Families for assistance to determine which program best fits their family’s needs. If members do not select a plan, Georgia Families will select a health plan for them.
Members can visit the Georgia Families Web site at www.georgia-families.com or call 1-800-GA-ENROLL (1-888423-6765) to speak to a representative who can give them information about the CMOs and the health care providers. he following categories of eligibility are included and excluded under Georgia Families:

Included Categories of Eligibility (COE):
COE
104
105
118

DESCRIPTION
LIM – Adult
LIM – Child

119

LIM – 1 Yr Trans Med Ast Child
CS Adult 4 Month Extended
CS Child 4 Month Extended
Stepchild
Newborn Child
RSM Pregnant Women
RSM Child
P4HB Inter Pregnancy Care
P4HB Family Planning Only
P4HB ROMC - LIM
P4HB ROMC - ABD
RSM Expansion Pregnant Women
RSM Expansion Child < 1 Yr
RSM Expn Child w/DOB < =
10/1/83
RSM Preg Women Income < 185
FPL
Women’s Health Medicaid
RSM Child
Refugee (DMP) – Adult
Refugee (DMP) – Child
Post Ref Extended Med – Adult
Post Ref Extended Med – Child
Refugee MAO – Adult
Refugee MAO – Child

122
123
126
135
170
171
180
181
182
183
194
195
196
197
245
471
506
507
508
509
510
511

st

LIM – 1 Yr Trans Med Ast Adult st Physicians’ Injectable Drug List (PIDL) – October 2013

C-2

Schedule of Maximum Allowable
571
595
596
790
791
792
793
800
835
836
865
871
876
894
895
897
898
918
919
920
921

Refugee RSM - Child
Refugee RSM Exp. Child < 1
Refugee RSM Exp Child DOB 235% FPL
Presumptive WHM
Newborn
Newborn (DFACS)
Presumptive Pregnant Woman
RSM (DHACS)
RSM Pregnant Women (DHACS)
RSM Exp Pregnant Women
(DHACS)
RSM Exp Child < 1 (DHACS)
RSM Pregnant Women Income >
185% FPL (DHACS)
RSM Child < 1 Moth Aid = 897
(DHACS)
LIM Adult
LIM Child
Refugee Adult
Refugee Child

Physicians’ Injectable Drug List (PIDL) – October 2013

C-3