MEDICALLY NECESSARY |
|
J7170 Injection, emicizumab-kxwh, 0.5 mg |
|
J7177 Injection, human fibrinogen
concentrate (fibryga), 1 mg |
|
J7179 Injection, von Willebrand factor
(recombinant), (Vonvendi), 1 IU VWF:RCo |
|
J7182 Injection, factor VIII,
(antihemophilic factor, recombinant), (NovoEight), per IU |
|
J7183 Injection, von Willebrand factor
complex (human), Wilate, 1 IU vWF:RCo |
|
J7185 Injection, factor VIII
(antihemophilic factor, recombinant) (Xyntha), per IU |
|
J7187 Injection, von Willebrand factor
complex (Humate-P), per IU VWF:RCO |
|
J7189 Factor viia (antihemophilic factor,
recombinant), (novoseven rt), 1 microgram |
|
J7200 Injection, factor IX,
(antihemophilic factor, recombinant), Rixubis, per IU |
|
J7201 Injection, factor IX, Fc fusion
protein, (recombinant), Alprolix, 1 IU |
|
J7202 Injection, factor IX, albumin
fusion protein, (recombinant), Idelvion, 1 IU |
|
J7203 Injection factor ix,
(antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu |
|
J7204 Injection, factor viii,
antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu |
|
J7208 Injection, factor viii,
(antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. |
|
J7209 Injection, factor VIII,
(antihemophilic factor, recombinant), (Nuwiq), 1 IU |
|
J7210 Injection, factor viii,
(antihemophilic factor, recombinant), (Afstyla), 1 I.U. |
|
J7211 Injection, factor viii,
(antihemophilic factor, recombinant), (Kovaltry), 1 I.U. |
|
J7212 Factor viia (antihemophilic factor,
recombinant)-jncw (sevenfact), 1 microgram |
|
J7213 Injection, coagulation factor ix
(recombinant), ixinity, 1 i.u. |
|
J7214 Injection, Factor VIII/von
Willebrand factor complex, recombinant (Altuviiio), per Factor VIII IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Hympavzi:
|
C9399 Unclassified drugs or biologicals
|
J3590 Unclassified biologics |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Coagadex®: |
|
J7175 Injection, factor X, (human), 1 IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
RiaSTAP®: |
|
J7178 Injection, human fibrinogen
concentrate, not otherwise specified, 1 mg |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Corifact®: |
|
J7180 Injection, factor XIII
(antihemophilic factor, human), 1 IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Tretten®: |
|
J7181 Injection, factor XIII A-subunit,
(recombinant), per IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Alphanate®: |
|
J7186 Injection, antihemophilic factor
VIII/von Willebrand factor complex (human), per factor VIII i.u. |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Obizur: |
|
J7188 Injection, factor VIII
(antihemophilic factor, recombinant), per IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Koate®DVI and Hemofil M: |
|
J7190 Factor VIII (antihemophilic factor,
human) per IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Advate®, Kogenate FS®, and Recombinate®: |
|
J7192 Factor VIII (antihemophilic factor,
recombinant) per IU, not otherwise specified |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Alphanine® SD: |
|
J7193 Factor IX (antihemophilic factor,
purified, nonrecombinant) per IU |
|
THE FOLLOWING CODE IS USED TO REPRESENT
Profilnine®: |
|
J7194 Factor IX complex, per IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
BeneFIX®: |
|
J7195 Injection, factor IX
(antihemophilic factor, recombinant) per IU, not otherwise specified |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
FEIBA (human plasma-derived activated prothrombin complex concentrate
[APCC]): |
|
J7198 Antiinhibitor, per IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Eloctate®: |
|
J7205 Injection, factor VIII Fc fusion
protein (recombinant), per IU |
|
|
THE FOLLOWING CODE IS USED TO REPRESENT
Adynovate: |
|
J7207 Injection, factor VIII,
(antihemophilic factor, recombinant), PEGylated, 1 IU
|
|
NOT ELIGIBLE FOR
REIMBURSEMENT |
|
THE FOLLOWING CODES REPRESENT BEBULIN,
HELIXATE® FS, HYATE:C®, MONOCLATE-P®, MONONINE®,
NOVOSEVEN®, PROFILNINE®SD, AND REFACTO® WHICH ARE NO LONGER
MANUFACTURED AND HAVE BEEN WITHDRAWN FROM THE MARKET: |
|
J7189 Factor VIIa (atihemophilic factor,
recombinant), per 1 mcg |
J7190 Factor VIII (antihemophilic factor,
human) per IU |
J7191 Factor VIII (antihemophilic factor
(porcine), per IU |
J7192 Factor VIII (antihemophilic factor,
recombinant) per IU, not otherwise specified |
J7193 Factor IX (antihemophilic factor,
purified, nonrecombinant) per IU |
J7194 Factor IX complex, per IU
|