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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.