Injectable Medication Codes Subject to MRxM Claim Review/Editing

Magellan Rx Management will review submitted claims that include the HCPCS codes representing injectable medications listed in this section to help ensure that the billing details are appropriate per Horizon BCBSNJ medical policy guidelines.

This list, which is organized alphabetically by brand name, was last revised on September 25, 2023..

The injectable medications in this section DO NOT require MNAR as part of the Horizon BCBSNJ Medical Injectables Program (MIP).

Medication Brand Name	Generic Medication Name	HCPCS Code(s)	NDC
Alimta®	pemetrexed	J9305
Beovu®	brolucizumab-dbll	J0179
Botox®	onabotulinumtoxina	J0585
Byooviz™	ranibizumab-nuna	Q5124
Camcevi™	leuprolide	J1952
Cimerli™	ranibizumab-eqrn	Q5128
Dextenza®	dexamethasone ophthalmic insert	J1096
Durysta Implant®	bimatoprost implant	J7351
Dysport®	abobotulinumtoxina	J0586
Eligard®	leuprolide acetate (for depot suspension)	J9217
Emend®	fosaprepitant	J1453
Euflexxa®	1% sodium hyaluronate	J7323
Eylea®	aflibercept	J0178
Faslodex®	fulvestrant	J9395, J9393
Fensolvi®	leuprolide acetate (for depot suspension)	J1951
Firmagon®	degarelix	J9155
Fosaprepitant (generic mfd. by Teva)	fosaprepitant	J1456
Fulvestrant (generic mfd. by Teva)	fulvestrant (Teva)	J9393
Granix®	bo-filgrastim	J1447
Halaven®	eribulin	J9179
Ilaris®	canakinumab	J0638
Iluvien®	fluocinonide acetonide intravitreal implant	J7313
Lucentis®	ranibizumab	J2778
Lupron Depot®	leuprolide acetate (for depot suspension)	J1950
Lutrate Depot	leuprolide acetate (for depot suspension)	J1954
Macugen®	pegaptanib sodium	J2503
Monovisc®	high molecular weight hyaluronan injection	J7327
Myobloc®	rimabotulinumtoxinb	J0587
Orthovisc®	hyaluronic acid	J7324
Ozurdex®	dexamethasone intravitreal implant	J7312
Pemetrexed (generic mfd by Accord)	pemetrexed (Accord)	J9296
Pemetrexed (generic mfd. by Bluepoint)	pemetrexed (Bluepoint)	J9322
Pemetrexed (generic mfd. by Hospira)	pemetrexed (Hospira)	J9294
Pemetrexed (generic mfd. by Sandoz)	pemetrexed (Sandoz)	J9297
Pemetrexed-ditromethamine (generic mfd. by Hospira)	pemetrexed-ditromethamine (Hospira)	J9323
Retisert®	fluocinonide acetonide intravitreal implant	J7311
Rystiggo®	rozanolixizumab-noli	J3590	50474-980-79
Sunlenca®	lenacapavir	J1961
Supprelin LA®	histrelin	J9226
Synvisc®/Synvisc-One®	hylan G-F 20	J7325
Trelstar®	triptorelin pamoate	J3315
Triptodur®	triptorelin	J3316
Vantas®	histrelin acetate	J9225
Xeomin®	incobotulinumtoxina	J0588
Xiaflex®	Collagenase clostridium histolyticum	J0775
Xipere™	Triamcinolone acetonide injectable suspension	J3299
Velcade®	bortezomib	J9041
Yutiq®	fluocinonide acetonide intravitreal implant	J7314
Zarxio®	filgrastim-sndz	Q5101
Zolodex®	goserelin acetate implant	J9202

Recent/Upcoming program changes:

Effective October 1, 2023 Granix and Zarxio will be reviewed as part of this program
Effective September 25,2023, Sunlenca will be reviewed as part of this program
Effective September 28, 2023, Velcade will be reviewed as part of this program.
Effective September 28, 2023, MRxM will perform Medical Necessity and Appropriateness Review (MNAR) of Pemfexy.
Effective September 22, 2023, Rystiggo will be reviewed as part of this program.
Effective July 14, 2023, pemetrexed (mfd. by Bluepoint), pemetrexed (mfd. By Shilpa) and pemetrexed-ditromethamine (mfd. by Hospira) will also be reviewed as part of this program.
Effective June 18, 2023, Cimerli, generic pemetrexed (mfd. by Hospira), generic pemetrexed (mfd. by Accord) and generic pemetrexed (mfd. by Sandoz) will also be reviewed as part of this program.
Effective January 1, 2023, generic fosaprepitant (mfd. by Teva), generic fosaprepitant (mfd. by Teva) and Lutrate Depot will also be reviewed as part of this program.