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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.