Site of Administration Program Code List
Claims submitted for the infusion/injectable therapy drugs listed below for Horizon members living in NJ and receiving treatments at a hospital outpatient facility are processed according to the guidelines of our Site of Administration for Infusion and Injectable Prescription Medications medical policy.
The drugs below are organized alphabetically by generic drug name. This information was posted on June 19, 2023 and is subject to change.
| Generic Name | Brand Name | HCPCS | NDC Code(s) |
|---|---|---|---|
| abatacept | Orencia™ | J0129 | |
| agalsidase beta | Fabrazyme® | J0180 | |
| alemtuzumab | Lemtrada | J0202 | |
| alglucosidase alfa | Lumizyme® | J0221 | |
| alpha-1-proteinase inhibitor | Glassia™ | J0257 | |
| alpha-1-proteinase inhibitor | Zemaira™ | J0256 | |
| anifrolumab-fnia | Saphnelo™ | J0491 | |
| avalglucosidase alfa-ngpt | Nexviazyme™ | J0219 | |
| belimumab | Benlysta® | J0490 | |
| benralizumab | Fasenra® | J0517 | |
| burosumab-twza | Crysvita™ | J0584 | |
| casimersen | Amondys 45™ | J1426 | |
| certolizumab pegol | Cimzia™ | J0717 | |
| crizanlizumab-tmca | Adakveo™ | J0791 | |
| eculizumab | Soliris® | J1300 | |
| edaravone | Radicava™ | J1301 | |
| efgartigimod | Vyvgart™ | J9332 | |
| elosulfase alfa | Vimizim™ | J1322 | |
| eptinezumab | Vyepti™ | J3032 | |
| eteplirsen | Exondys 51™ | J1428 | |
| evinacumab-dgnb | Evkeeza™ | J1305 | |
| galsulfase | Naglazyme® | J1458 | |
| givosiran | Givlaari™ | J0223 | |
| golimumab | Simponi Aria™ | J1602 | |
| golodirsen | Vyondys 53™ | J1429 | |
| human C1 inhibitor | Cinryze® | J0598 | |
| ibalizumab-uiyk | Trogarzo™ | J1746 | |
| idursulfase | Elaprase® | J1743 | |
| imiglucerase | Cerezyme® | J1786 | |
| immune globulin | Panzyga™ | J1599 | |
| immune globulin-intravenous | Asceniv® | J1554 | |
| immune globulin-intravenous | Bivigam® | J1556 | |
| immune globulin-intravenous | Carimune® NF, Gammagard® S/D | J1566 | |
| immune globulin-intravenous | Flebogamma® | J1572 | |
| immune globulin-intravenous | Gammaplex® | J1557 | |
| immune globulin-intravenous | Gamunex® | J1561 | |
| immune globulin-intravenous | Octagam® | J1568 | |
| immune globulin-intravenous | Privigen® | J1459 | |
| immune globulin-subcutaneous | Cutaquig® | J1551 | |
| immune globulin-subcutaneous | Cuvitru® | J1555 | |
| immune globulin-subcutaneous | Gammagard® liquid | J1569 | |
| immune globulin-subcutaneous | Hizentra® | J1559 | |
| immune globulin-subcutaneous | Hyqvia® | J1575 | |
| immune globulin-subcutaneous | Xembify® | J1558 | |
| inclisiran | Leqvio™ | J1306 | |
| inebilizumab- cdon | Uplizna™ | J1823 | |
| infliximab | Remicade™ | J1745 | |
| infliximab-abda | Renflexis™ | Q5104 | |
| infliximab-axxq | Avsola™ | Q5121 | |
| infliximab-dyyb | Inflectra™ | Q5103 | |
| infliximab-qbtx | Ixifi™ | J3590 | |
| lanreotide | Somatuline® Depot | J1930 | |
| laronidase | Aldurazyme® | J1931 | |
| lumasiran | Oxlumo™ | J0224 | |
| mepolizumab | Nucala™ | J2182 | |
| natalizumab | Tysabri™ | J2323 | |
| ocrelizumab | Ocrevus™ | J2350 | |
| octreotide acetate | Sandostatin® LAR Depot | J2353 | |
| omalizumab | Xolair® | J2357 | |
| patisran | Onpattro® | J0222 | |
| ravulizumab-cwz | Ultomiris® | J1303 | |
| reslizumab | Cinqair® | J2786 | |
| rituximab | Rituxan® (non-oncology indications only) | J9312 | |
| rituximab-abbs | Truxima® (non-oncology indications only) | Q5115 | |
| rituximab-arrx | Riabni® (non-oncology indications only) | Q5123 | |
| rituximab-pvvr | Ruxience® (non-oncology indications only) | Q5119 | |
| romosozumab-aqqg | Evenity™ | J3111 | |
| sebelipase alfa | Kanuma™ | J2840 | |
| taliglucerase alfa | Elelyso® | J3060 | |
| teprotumumab-trbw | Tepezza™ | J3241 | |
| tocilizumab | Actemra™ | J3262 | |
| ublituximab-xiiy | Briumvi™ | J9999, J3490, J3590 |
73150-0150-06 |
| ustekinumab | Stelara™ | J3357 | |
| vedolizumab | Entyvio™ | J3380 | |
| velaglucerase alfa | Vpriv® | J3385 | |
| velmanase alfa-tycv | Lamzede™ | J9999, J3490, J3590 |
10122-180-02, 10122-180-05, 10122-180-10 |
| vestronidase afla-vjbk | Mepsevii™ | J3397 | |
| viltolarsen | Viltepso™ | J1427 |
Recent Changes/Updates:
- Effective July 19, 2023, Briumvi and Lamzede are included as part of this program.
- Effective April 1, 2023, the following drugs are included in the scope of this program: Adakveo, Amondys 45, Avsola, Crysvita, Evenity, Evkeeza, Exondys 51, Givlaari, Glassia, Kanuma, Lemtrada, Leqvio, Mepsevii, Nexviazyme, Ocrevus, Oxlumo, Panzyga, Radicava, Rituxan, Saphnelo, Tepezza, Trogarzo, Tysabri, Uplizna, Viltepso, Vimizim, Vyepti, Vyondys 53, Vyvgart and Zemaira.
This document contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers that are not affiliated with either Horizon or the Blue Cross and Blue Shield Association.