Latest JW-Modifier list for medical drugs (CADs)

Date: January 12, 2023

Attention: All Providers

Effective date: January 1, 2023

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: The JW modifier is a Healthcare Common Procedure Coding System (HCPCS) modifier required to be reported on a claim to account for the amount of a drug that is discarded and eligible for payment. The modifier should only be used for claims that bill single-dose container drugs.

How this impacts providers: Provider reporting guidance:

Providers are required to report the JW modifier on all claims that bill for drugs and biological drugs separately payable under Medicaid. This includes unused and discarded amounts from single-dose containers or single- use packages/single-dose containers.
Providers must also document the amount of discarded drugs in the members’ medical records. Payers will use the JW modifiers to calculate discarded drug refunds.

Action providers must take: Providers and their billing offices/personnel should be aware of the most recent changes to the approved list of HCPCS codes eligible for JW-modifier billing. Failure to adhere to the list may result in potential waste/abuse investigations.

HCPCS Code	HCPCS Short Description	Start Date	End Date	Status
90284	HUMAN IG, SC	09/01/2020	12/31/3999	No Changes
90291	CMV IG, IV	09/01/2020	12/31/3999	No Changes
90371	HEP B IG, IM	09/01/2020	12/31/3999	No Changes
90376	RABIES IG, HEAT TREATED	09/01/2020	12/31/3999	No Changes
90377	RABIES IG HT&SOL HUMAN IM/SC	01/01/2021	12/31/3999	No Changes
C9142	INJ, ALYMSYS, 10 MG	10/01/2022	12/31/3999	New
C9257	BEVACIZUMAB INJECTION	09/01/2020	12/31/3999	No Changes
J0122	INJ., ERAVACYCLINE, 1 MG	09/01/2020	12/31/3999	No Changes
J0129	ABATACEPT INJECTION	09/01/2020	12/31/3999	No Changes
J0132	ACETYLCYSTEINE INJECTION	09/01/2020	12/31/3999	No Changes
J0133	ACYCLOVIR INJECTION	09/01/2020	12/31/3999	No Changes
J0171	ADRENALIN EPINEPHRINE INJECT	09/01/2020	12/31/3999	No Changes
J0172	INJ, ADUCANUMAB-AVWA, 2 MG	01/01/2022	12/31/3999	No Changes
J0180	AGALSIDASE BETA INJECTION	09/01/2020	12/31/3999	No Changes
J0207	AMIFOSTINE	09/01/2020	12/31/3999	No Changes
J0219	INJ AVAL ALFA-NQPT 4MG	04/01/2022	12/31/3999	No Changes
J0221	LUMIZYME INJECTION	09/01/2020	12/31/3999	No Changes
J0222	INJ., PATISIRAN, 0.1 MG	09/01/2020	12/31/3999	No Changes
J0223	INJ GIVOSIRAN 0.5 MG	09/01/2020	12/31/3999	No Changes
J0224	INJ. LUMASIRAN, 0.5 MG	07/01/2021	12/31/3999	No Changes
J0256	ALPHA 1 PROTEINASE INHIBITOR	09/01/2020	12/31/3999	No Changes
J0257	GLASSIA INJECTION	09/01/2020	12/31/3999	No Changes
J0278	AMIKACIN SULFATE INJECTION	09/01/2020	12/31/3999	No Changes
J0278	AMIKACIN SULFATE INJECTION	09/01/2020	12/31/3999	No Changes
J0280	AMINOPHYLLIN 250 MG INJ	09/01/2020	12/31/3999	No Changes
J0282	AMIODARONE HCL	09/01/2020	12/31/3999	No Changes
J0285	AMPHOTERICIN B	09/01/2020	12/31/3999	No Changes
J0287	AMPHOTERICIN B LIPID COMPLEX	09/01/2020	12/31/3999	No Changes
J0289	AMPHOTERICIN B LIPOSOME INJ	09/01/2020	12/31/3999	No Changes
J0290	AMPICILLIN 500 MG INJ	09/01/2020	12/31/3999	No Changes
J0291	INJ., PLAZOMICIN, 5 MG	09/01/2020	12/31/3999	No Changes
J0300	AMOBARBITAL 125 MG INJ	09/01/2020	12/31/3999	No Changes
J0330	SUCCINYCHOLINE CHLORIDE INJ	09/01/2020	12/31/3999	No Changes
J0360	HYDRALAZINE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J0401	INJ ARIPIPRAZOLE EXT REL 1MG	09/01/2020	12/31/3999	No Changes
J0461	ATROPINE SULFATE INJECTION	09/01/2020	12/31/3999	No Changes
J0470	DIMECAPROL INJECTION	09/01/2020	12/31/3999	No Changes
J0475	BACLOFEN 10 MG INJECTION	09/01/2020	12/31/3999	No Changes
J0485	BELATACEPT INJECTION	09/01/2020	12/31/3999	No Changes
J0490	BELIMUMAB INJECTION	09/01/2020	12/31/3999	No Changes
J0500	DICYCLOMINE INJECTION	09/01/2020	12/31/3999	No Changes
J0515	INJ BENZTROPINE MESYLATE	09/01/2020	12/31/3999	No Changes
J0517	INJ., BENRALIZUMAB, 1 MG	09/01/2020	12/31/3999	No Changes
J0558	PENG BENZATHINE/PROCAINE INJ	09/01/2020	12/31/3999	No Changes
J0561	PENICILLIN G BENZATHINE INJ	09/01/2020	12/31/3999	No Changes
J0565	INJ, BEZLOTOXUMAB, 10 MG	09/01/2020	12/31/3999	No Changes
J0583	BIVALIRUDIN	09/01/2020	12/31/3999	No Changes
J0585	INJECTION,ONABOTULINUMTOXINA	09/01/2020	12/31/3999	No Changes
J0586	ABOBOTULINUMTOXINA	09/01/2020	12/31/3999	No Changes
J0587	INJ, RIMABOTULINUMTOXINB	09/01/2020	12/31/3999	No Changes
J0588	INCOBOTULINUMTOXIN A	09/01/2020	12/31/3999	No Changes
J0592	BUPRENORPHINE HYDROCHLORIDE	09/01/2020	12/31/3999	No Changes
J0594	BUSULFAN INJECTION	09/01/2020	12/31/3999	No Changes
J0596	INJECTION, RUCONEST	09/01/2020	12/31/3999	No Changes
J0599	INJ., HAEGARDA 10 UNITS	09/01/2020	12/31/3999	No Changes
J0600	EDETATE CALCIUM DISODIUM INJ	09/01/2020	12/31/3999	No Changes
J0610	CALCIUM GLUCONATE INJECTION	09/01/2020	12/31/3999	No Changes
J0636	INJ CALCITRIOL PER 0.1 MCG	09/01/2020	12/31/3999	No Changes
J0637	CASPOFUNGIN ACETATE	09/01/2020	12/31/3999	No Changes
J0638	CANAKINUMAB INJECTION	09/01/2020	12/31/3999	No Changes
J0640	LEUCOVORIN CALCIUM INJECTION	09/01/2020	12/31/3999	No Changes
J0641	INJ., LEVOLEUCOVORIN, 0.5 MG	09/01/2020	12/31/3999	No Changes
J0670	INJ MEPIVACAINE HCL/10 ML	09/01/2020	12/31/3999	No Changes
J0692	CEFEPIME HCL FOR INJECTION	09/01/2020	12/31/3999	No Changes
J0694	CEFOXITIN SODIUM INJECTION	09/01/2020	12/31/3999	No Changes
J0696	CEFTRIAXONE SODIUM INJECTION	09/01/2020	12/31/3999	No Changes
J0698	CEFOTAXIME SODIUM INJECTION	09/01/2020	12/31/3999	No Changes
J0706	CAFFEINE CITRATE INJECTION	09/01/2020	12/31/3999	No Changes
J0713	INJ CEFTAZIDIME PER 500 MG	09/01/2020	12/31/3999	No Changes
J0720	CHLORAMPHENICOL SODIUM INJEC	09/01/2020	12/31/3999	No Changes
J0725	CHORIONIC GONADOTROPIN/1000U	09/01/2020	12/31/3999	No Changes
J0735	CLONIDINE HYDROCHLORIDE	09/01/2020	12/31/3999	No Changes
J0740	CIDOFOVIR INJECTION	09/01/2020	12/31/3999	No Changes
J0770	COLISTIMETHATE SODIUM INJ	09/01/2020	12/31/3999	No Changes
J0780	PROCHLORPERAZINE INJECTION	09/01/2020	12/31/3999	No Changes
J0791	INJ CRIZANLIZUMAB-TMCA 5MG	09/01/2020	12/31/3999	No Changes
J0795	CORTICORELIN OVINE TRIFLUTAL	09/01/2020	12/31/3999	No Changes
J0800	CORTICOTROPIN INJECTION	09/01/2020	12/31/3999	No Changes
J0834	COSYNTROPIN CORTROSYN INJ	09/01/2020	12/31/3999	No Changes
J0850	CYTOMEGALOVIRUS IMM IV /VIAL	09/01/2020	12/31/3999	No Changes
J0878	DAPTOMYCIN INJECTION	09/01/2020	12/31/3999	No Changes
J0881	DARBEPOETIN ALFA, NON-ESRD	09/01/2020	12/31/3999	No Changes
J0882	DARBEPOETIN ALFA, ESRD USE	09/01/2020	12/31/3999	No Changes
J0883	ARGATROBAN NONESRD USE 1MG	09/01/2020	12/31/3999	No Changes
J0885	EPOETIN ALFA, NON-ESRD	09/01/2020	12/31/3999	No Changes
J0887	EPOETIN BETA ESRD USE	09/01/2020	12/31/3999	No Changes
J0888	EPOETIN BETA NON ESRD	09/01/2020	12/31/3999	No Changes
J0894	DECITABINE INJECTION	09/01/2020	12/31/3999	No Changes
J0896	INJ LUSPATERCEPT-AAMT 0.25MG	09/01/2020	12/31/3999	No Changes
J1000	DEPO-ESTRADIOL CYPIONATE INJ	09/01/2020	12/31/3999	No Changes
J1020	METHYLPREDNISOLONE 20 MG INJ	09/01/2020	12/31/3999	No Changes
J1030	METHYLPREDNISOLONE 40 MG INJ	09/01/2020	12/31/3999	No Changes
J1040	METHYLPREDNISOLONE 80 MG INJ	09/01/2020	12/31/3999	No Changes
J1071	INJ TESTOSTERONE CYPIONATE	09/01/2020	12/31/3999	No Changes
J1100	DEXAMETHASONE SODIUM PHOS	09/01/2020	12/31/3999	No Changes
J1120	ACETAZOLAMID SODIUM INJECTIO	09/01/2020	12/31/3999	No Changes
J1160	DIGOXIN INJECTION	09/01/2020	12/31/3999	No Changes
J1165	PHENYTOIN SODIUM INJECTION	09/01/2020	12/31/3999	No Changes
J1170	HYDROMORPHONE INJECTION	09/01/2020	12/31/3999	No Changes
J1190	DEXRAZOXANE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J1200	DIPHENHYDRAMINE HCL INJECTIO	09/01/2020	12/31/3999	No Changes
J1201	INJ. CETIRIZINE HCL 0.5MG	09/01/2020	12/31/3999	No Changes
J1205	CHLOROTHIAZIDE SODIUM INJ	09/01/2020	12/31/3999	No Changes
J1212	DIMETHYL SULFOXIDE 50% 50 ML	09/01/2020	12/31/3999	No Changes
J1230	METHADONE INJECTION	09/01/2020	12/31/3999	No Changes
J1240	DIMENHYDRINATE INJECTION	09/01/2020	12/31/3999	No Changes
J1245	DIPYRIDAMOLE INJECTION	09/01/2020	12/31/3999	No Changes
J1250	INJ DOBUTAMINE HCL/250 MG	09/01/2020	12/31/3999	No Changes
J1265	DOPAMINE INJECTION	09/01/2020	12/31/3999	No Changes
J1267	DORIPENEM INJECTION	09/01/2020	12/31/3999	No Changes
J1270	INJECTION, DOXERCALCIFEROL, 1 MCG	09/01/2020	12/31/3999	No Changes
J1302	INJ, SUTIMLIMAB-JOME, 10 MG	10/01/2022	12/31/3999	New
J1305	INJ, EVINACUMAB-DGNB, 5MG	10/01/2021	12/31/3999	No Changes
J1322	ELOSULFASE ALFA, INJECTION	09/01/2020	12/31/3999	No Changes
J1324	ENFUVIRTIDE INJECTION	09/01/2020	12/31/3999	No Changes
J1325	EPOPROSTENOL INJECTION	09/01/2020	12/31/3999	No Changes
J1327	EPTIFIBATIDE INJECTION	09/01/2020	12/31/3999	No Changes
J1335	ERTAPENEM INJECTION	09/01/2020	12/31/3999	No Changes
J1364	ERYTHRO LACTOBIONATE /500 MG	09/01/2020	12/31/3999	No Changes
J1410	INJ ESTROGEN CONJUGATE 25 MG	09/01/2020	12/31/3999	No Changes
J1426	INJECTION, CASIMERSEN, 10 MG	10/01/2021	12/31/3999	No Changes
J1427	INJ. VILTOLARSEN	04/01/2021	12/31/3999	No Changes
J1428	INJ, ETEPLIRSEN, 10 MG	09/01/2020	12/31/3999	No Changes
J1429	INJ GOLODIRSEN 10 MG	09/01/2020	12/31/3999	No Changes
J1437	INJ. FE DERISOMALTOSE 10 MG	04/01/2021	12/31/3999	No Changes
J1438	ETANERCEPT INJECTION	09/01/2020	12/31/3999	No Changes
J1439	INJ FERRIC CARBOXYMALTOS 1MG	09/01/2020	12/31/3999	No Changes
J1442	INJ, FILGRASTIM G-CSF 1MCG	09/01/2020	12/31/3999	No Changes
J1447	INJ TBO FILGRASTIM 1 MICROG	09/01/2020	12/31/3999	No Changes
J1448	INJECTION, TRILACICLIB, 1MG	10/01/2021	12/31/3999	No Changes
J1450	FLUCONAZOLE	09/01/2020	12/31/3999	No Changes
J1451	FOMEPIZOLE, 15 MG	09/01/2020	12/31/3999	No Changes
J1458	GALSULFASE INJECTION	09/01/2020	12/31/3999	No Changes
J1459	INJ IVIG PRIVIGEN 500 MG	09/01/2020	12/31/3999	No Changes
J1460	GAMMA GLOBULIN 1 CC INJ	09/01/2020	12/31/3999	No Changes
J1551	INJ CUTAQUIG 100 MG	07/01/2022	12/31/3999	No Changes
J1554	INJ. ASCENIV	04/01/2021	12/31/3999	No Changes
J1555	INJ CUVITRU, 100 MG	09/01/2020	12/31/3999	No Changes
J1556	INJ, IMM GLOB BIVIGAM, 500MG	09/01/2020	12/31/3999	No Changes
J1557	GAMMAPLEX INJECTION	09/01/2020	12/31/3999	No Changes
J1559	HIZENTRA INJECTION	09/01/2020	12/31/3999	No Changes
J1561	GAMUNEX-C/GAMMAKED	09/01/2020	12/31/3999	No Changes
J1566	IMMUNE GLOBULIN, POWDER	09/01/2020	12/31/3999	No Changes
J1568	OCTAGAM INJECTION	09/01/2020	12/31/3999	No Changes
J1569	GAMMAGARD LIQUID INJECTION	09/01/2020	12/31/3999	No Changes
J1570	GANCICLOVIR SODIUM INJECTION	09/01/2020	12/31/3999	No Changes
J1571	HEPAGAM B IM INJECTION	09/01/2020	12/31/3999	No Changes
J1572	FLEBOGAMMA INJECTION	09/01/2020	12/31/3999	No Changes
J1573	HEPAGAM B INTRAVENOUS, INJ	09/01/2020	12/31/3999	No Changes
J1575	HYQVIA 100MG IMMUNOGLOBULIN	09/01/2020	12/31/3999	No Changes
J1580	GARAMYCIN GENTAMICIN INJ	09/01/2020	12/31/3999	No Changes
J1602	GOLIMUMAB FOR IV USE 1MG	09/01/2020	12/31/3999	No Changes
J1610	GLUCAGON HYDROCHLORIDE/1 MG	09/01/2020	12/31/3999	No Changes
J1626	GRANISETRON HCL INJECTION	09/01/2020	12/31/3999	No Changes
J1627	INJ, GRANISETRON, XR, 0.1 MG	09/01/2020	12/31/3999	No Changes
J1630	HALOPERIDOL INJECTION	09/01/2020	12/31/3999	No Changes
J1631	HALOPERIDOL DECANOATE INJ	09/01/2020	12/31/3999	No Changes
J1632	INJ., BREXANOLONE, 1 MG	10/01/2020	12/31/3999	No Changes
J1640	HEMIN, 1 MG	09/01/2020	12/31/3999	No Changes
J1642	INJ HEPARIN SODIUM PER 10 U	09/01/2020	12/31/3999	No Changes
J1644	INJ HEPARIN SODIUM PER 1000U	09/01/2020	12/31/3999	No Changes
J1645	DALTEPARIN SODIUM	09/01/2020	12/31/3999	No Changes
J1650	INJ ENOXAPARIN SODIUM	09/01/2020	12/31/3999	No Changes
J1652	FONDAPARINUX SODIUM	09/01/2020	12/31/3999	No Changes
J1670	TETANUS IMMUNE GLOBULIN INJ	09/01/2020	12/31/3999	No Changes
J1720	HYDROCORTISONE SODIUM SUCC I	09/01/2020	12/31/3999	No Changes
J1741	IBUPROFEN INJECTION	09/01/2020	12/31/3999	No Changes
J1742	IBUTILIDE FUMARATE INJECTION	09/01/2020	12/31/3999	No Changes
J1743	IDURSULFASE INJECTION	09/01/2020	12/31/3999	No Changes
J1745	INFLIXIMAB INJECTION	09/01/2020	12/31/3999	No Changes
J1750	INJ IRON DEXTRAN	09/01/2020	12/31/3999	No Changes
J1756	IRON SUCROSE INJECTION	09/01/2020	12/31/3999	No Changes
J1786	IMUGLUCERASE INJECTION	09/01/2020	12/31/3999	No Changes
J1790	DROPERIDOL INJECTION	09/01/2020	12/31/3999	No Changes
J1800	PROPRANOLOL INJECTION	09/01/2020	12/31/3999	No Changes
J1826	INTERFERON BETA-1A INJ	09/01/2020	12/31/3999	No Changes
J1830	INTERFERON BETA-1B / .25 MG	09/01/2020	12/31/3999	No Changes
J1885	KETOROLAC TROMETHAMINE INJ	09/01/2020	12/31/3999	No Changes
J1931	LARONIDASE INJECTION	09/01/2020	12/31/3999	No Changes
J1940	FUROSEMIDE INJECTION	09/01/2020	12/31/3999	No Changes
J1943	INJ., ARISTADA INITIO, 1 MG	09/01/2020	12/31/3999	No Changes
J1944	ARIPIRAZOLE LAUROXIL 1 MG	09/01/2020	12/31/3999	No Changes
J1953	LEVETIRACETAM INJECTION	09/01/2020	12/31/3999	No Changes
J1955	INJ LEVOCARNITINE PER 1 GM	09/01/2020	12/31/3999	No Changes
J1956	LEVOFLOXACIN INJECTION	09/01/2020	12/31/3999	No Changes
J1956	LEVOFLOXACIN INJECTION	09/01/2020	12/31/3999	No Changes
J1980	HYOSCYAMINE SULFATE INJ	09/01/2020	12/31/3999	No Changes
J2010	LINCOMYCIN INJECTION	09/01/2020	12/31/3999	No Changes
J2020	INJECTION, LINEZOLID, 200 MG	09/01/2020	12/31/3999	New
J2060	LORAZEPAM INJECTION	09/01/2020	12/31/3999	No Changes
J2150	MANNITOL INJECTION	09/01/2020	12/31/3999	No Changes
J2175	MEPERIDINE HYDROCHL /100 MG	09/01/2020	12/31/3999	No Changes
J2248	MICAFUNGIN SODIUM INJECTION	09/01/2020	12/31/3999	No Changes
J2250	INJ MIDAZOLAM HYDROCHLORIDE	09/01/2020	12/31/3999	No Changes
J2260	INJ MILRINONE LACTATE / 5 ML	09/01/2020	12/31/3999	No Changes
J2270	MORPHINE SULFATE INJECTION	09/01/2020	12/31/3999	No Changes
J2300	INJ NALBUPHINE HYDROCHLORIDE	09/01/2020	12/31/3999	No Changes
J2310	INJ NALOXONE HYDROCHLORIDE	09/01/2020	12/31/3999	No Changes
J2355	OPRELVEKIN INJECTION	09/01/2020	12/31/3999	No Changes
J2400	CHLOROPROCAINE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J2405	ONDANSETRON HCL INJECTION	09/01/2020	12/31/3999	No Changes
J2425	PALIFERMIN INJECTION	09/01/2020	12/31/3999	No Changes
J2501	PARICALCITOL	09/01/2020	12/31/3999	No Changes
J2504	PEGADEMASE BOVINE, 25 IU	09/01/2020	12/31/3999	No Changes
J2550	PROMETHAZINE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J2560	PHENOBARBITAL SODIUM INJ	09/01/2020	12/31/3999	No Changes
J2562	PLERIXAFOR INJECTION	09/01/2020	12/31/3999	No Changes
J2597	INJ DESMOPRESSIN ACETATE	09/01/2020	12/31/3999	No Changes
J2690	PROCAINAMIDE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J2710	NEOSTIGMINE METHYLSLFTE INJ	09/01/2020	12/31/3999	No Changes
J2724	PROTEIN C CONCENTRATE	09/01/2020	12/31/3999	No Changes
J2765	METOCLOPRAMIDE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J2770	QUINUPRISTIN/DALFOPRISTIN	09/01/2020	12/31/3999	No Changes
J2780	RANITIDINE HYDROCHLORIDE INJ	09/01/2020	12/31/3999	No Changes
J2786	INJECTION, RESLIZUMAB, 1MG	09/01/2020	12/31/3999	No Changes
J2788	RHO D IMMUNE GLOBULIN 50 MCG	09/01/2020	12/31/3999	No Changes
J2790	RHO D IMMUNE GLOBULIN INJ	09/01/2020	12/31/3999	No Changes
J2791	RHOPHYLAC INJECTION	09/01/2020	12/31/3999	No Changes
J2792	RHO(D) IMMUNE GLOBULIN H, SD	09/01/2020	12/31/3999	No Changes
J2796	ROMIPLOSTIM INJECTION	09/01/2020	12/31/3999	No Changes
J2820	SARGRAMOSTIM INJECTION	09/01/2020	12/31/3999	No Changes
J2840	INJ SEBELIPASE ALFA 1 MG	09/01/2020	12/31/3999	No Changes
J2920	METHYLPREDNISOLONE INJECTION	09/01/2020	12/31/3999	No Changes
J2930	METHYLPREDNISOLONE INJECTION	09/01/2020	12/31/3999	No Changes
J2997	ALTEPLASE RECOMBINANT	09/01/2020	12/31/3999	No Changes
J2998	INJ PLASMINOGEN TVMH 1MG	07/01/2022	12/31/3999	No Changes
J3000	STREPTOMYCIN INJECTION	09/01/2020	12/31/3999	No Changes
J3000	STREPTOMYCIN INJECTION	09/01/2020	12/31/3999	No Changes
J3010	FENTANYL CITRATE INJECTION	09/01/2020	12/31/3999	No Changes
J3030	SUMATRIPTAN SUCCINATE / 6 MG	09/01/2020	12/31/3999	No Changes
J3060	INJ, TALIGLUCERACE ALFA 10 U	09/01/2020	12/31/3999	No Changes
J3070	PENTAZOCINE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J3095	TELEVANCIN INJECTION	09/01/2020	12/31/3999	No Changes
J3101	TENECTEPLASE INJECTION	09/01/2020	12/31/3999	No Changes
J3105	TERBUTALINE SULFATE INJ	09/01/2020	12/31/3999	No Changes
J3121	INJ TESTOSTERO ENANTHATE 1MG	09/01/2020	12/31/3999	No Changes
J3145	TESTOSTERONE UNDECANOATE 1MG	09/01/2020	12/31/3999	No Changes
J3230	CHLORPROMAZINE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J3240	THYROTROPIN INJECTION	09/01/2020	12/31/3999	No Changes
J3241	INJ. TEPROTUMUMAB-TRBW 10 MG	10/01/2020	12/31/3999	No Changes
J3243	TIGECYCLINE INJECTION	09/01/2020	12/31/3999	No Changes
J3250	TRIMETHOBENZAMIDE HCL INJ	09/01/2020	12/31/3999	No Changes
J3260	TOBRAMYCIN SULFATE INJECTION	09/01/2020	12/31/3999	No Changes
J3262	TOCILIZUMAB INJECTION	09/01/2020	12/31/3999	No Changes
J3285	TREPROSTINIL INJECTION	09/01/2020	12/31/3999	No Changes
J3300	TRIAMCINOLONE A INJ PRS-FREE	09/01/2020	12/31/3999	No Changes
J3301	TRIAMCINOLONE ACET INJ NOS	09/01/2020	12/31/3999	No Changes
J3303	TRIAMCINOLONE HEXACETONL INJ	09/01/2020	12/31/3999	No Changes
J3304	INJ TRIAMCINOLONE ACE XR 1MG	09/01/2020	12/31/3999	No Changes
J3360	DIAZEPAM INJECTION	09/01/2020	12/31/3999	No Changes
J3370	VANCOMYCIN HCL INJECTION	09/01/2020	12/31/3999	No Changes
J3385	VELAGLUCERASE ALFA	09/01/2020	12/31/3999	No Changes
J3396	VERTEPORFIN INJECTION	09/01/2020	12/31/3999	No Changes
J3397	INJ., VESTRONIDASE ALFA-VJBK	09/01/2020	12/31/3999	No Changes
J3398	INJ LUXTURNA 1 BILLION VEC G	09/01/2020	12/31/3999	No Changes
J3410	HYDROXYZINE HCL INJECTION	09/01/2020	12/31/3999	No Changes
J3411	THIAMINE HCL 100 MG	09/01/2020	12/31/3999	No Changes
J3415	PYRIDOXINE HCL 100 MG	09/01/2020	12/31/3999	No Changes
J3420	VITAMIN B12 INJECTION	09/01/2020	12/31/3999	No Changes
J3430	VITAMIN K PHYTONADIONE INJ	09/01/2020	12/31/3999	No Changes
J3465	INJECTION, VORICONAZOLE	09/01/2020	12/31/3999	No Changes
J3470	HYALURONIDASE INJECTION	09/01/2020	12/31/3999	No Changes
J3471	OVINE, UP TO 999 USP UNITS	09/01/2020	12/31/3999	No Changes
J3472	OVINE, 1000 USP UNITS	09/01/2020	12/31/3999	No Changes
J3473	HYALURONIDASE RECOMBINANT	09/01/2020	12/31/3999	No Changes
J3475	INJ MAGNESIUM SULFATE	09/01/2020	12/31/3999	No Changes
J3480	INJ POTASSIUM CHLORIDE	09/01/2020	12/31/3999	No Changes
J3485	ZIDOVUDINE	09/01/2020	12/31/3999	No Changes
J3486	ZIPRASIDONE MESYLATE	09/01/2020	12/31/3999	No Changes
J7168	PROTHROMBIN COMPLEX KCENTRA	07/01/2021	12/31/3999	No Changes
J7170	INJ., EMICIZUMAB-KXWH 0.5 MG	09/01/2020	12/31/3999	No Changes
J7175	INJ, FACTOR X, (HUMAN), 1IU	09/01/2020	12/31/3999	No Changes
J7177	INJ., FIBRYGA, 1 MG	09/01/2020	12/31/3999	No Changes
J7178	HUMAN FIBRINOGEN CONC INJ	09/01/2020	12/31/3999	No Changes
J7179	VONVENDI INJ 1 IU VWF:RCO	09/01/2020	12/31/3999	No Changes
J7180	FACTOR XIII ANTI-HEM FACTOR	09/01/2020	12/31/3999	No Changes
J7181	FACTOR XIII RECOMB A-SUBUNIT	09/01/2020	12/31/3999	No Changes
J7182	FACTOR VIII RECOMB NOVOEIGHT	09/01/2020	12/31/3999	No Changes
J7183	WILATE INJECTION	09/01/2020	12/31/3999	No Changes
J7185	XYNTHA INJ	09/01/2020	12/31/3999	No Changes
J7186	ANTIHEMOPHILIC VIII/VWF COMP	09/01/2020	12/31/3999	No Changes
J7187	HUMATE-P, INJ	09/01/2020	12/31/3999	No Changes
J7188	FACTOR VIII RECOMB OBIZUR	09/01/2020	12/31/3999	No Changes
J7189	FACTOR VIIA	09/01/2020	12/31/3999	No Changes
J7190	FACTOR VIII	09/01/2020	12/31/3999	No Changes
J7192	FACTOR VIII RECOMBINANT NOS	09/01/2020	12/31/3999	No Changes
J7193	FACTOR IX NON-RECOMBINANT	09/01/2020	12/31/3999	No Changes
J7194	FACTOR IX COMPLEX	09/01/2020	12/31/3999	No Changes
J7195	FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.	09/01/2020	12/31/3999	No Changes
J7196	ANTITHROMBIN RECOMBINANT	09/01/2020	12/31/3999	No Changes
J7197	ANTITHROMBIN III INJECTION	09/01/2020	12/31/3999	No Changes
J7198	ANTI-INHIBITOR	09/01/2020	12/31/3999	No Changes
J7200	FACTOR IX RECOMBINAN RIXUBIS	09/01/2020	12/31/3999	No Changes
J7201	FACTOR IX FC FUSION RECOMB	09/01/2020	12/31/3999	No Changes
J7202	FACTOR IX IDELVION INJ	09/01/2020	12/31/3999	No Changes
J7203	FACTOR IX RECOMB GLY REBINYN	09/01/2020	12/31/3999	No Changes
J7204	INJ RECOMBIN ESPEROCT PER IU	09/01/2020	12/31/3999	No Changes
J7205	FACTOR VIII FC FUSION RECOMB	09/01/2020	12/31/3999	No Changes
J7207	FACTOR VIII PEGYLATED RECOMB	09/01/2020	12/31/3999	No Changes
J7208	INJ. JIVI 1 IU	09/01/2020	12/31/3999	No Changes
J7209	FACTOR VIII NUWIQ RECOMB 1IU	09/01/2020	12/31/3999	No Changes
J7210	INJ, AFSTYLA, 1 I.U.	09/01/2020	12/31/3999	No Changes
J7211	INJ, KOVALTRY, 1 I.U.	09/01/2020	12/31/3999	No Changes
J7212	FACTOR VIIA RECOMB SEVENFACT	04/01/2021	12/31/3999	No Changes
J7501	AZATHIOPRINE PARENTERAL	09/01/2020	12/31/3999	No Changes
J7504	LYMPHOCYTE IMMUNE GLOBULIN	09/01/2020	12/31/3999	No Changes
J7511	ANTITHYMOCYTE GLOBULN RABBIT	09/01/2020	12/31/3999	No Changes
J7516	CYCLOSPORIN PARENTERAL 250MG	09/01/2020	12/31/3999	No Changes
J7525	TACROLIMUS INJECTION	09/01/2020	12/31/3999	No Changes
J9000	DOXORUBICIN HCL INJECTION	09/01/2020	12/31/3999	No Changes
J9017	ARSENIC TRIOXIDE INJECTION	09/01/2020	12/31/3999	No Changes
J9019	ERWINAZE INJECTION	09/01/2020	12/31/3999	No Changes
J9021	INJ, ASPARA, RYLAZE, 0.1 MG	01/01/2022	12/31/3999	No Changes
J9022	INJ, ATEZOLIZUMAB,10 MG	09/01/2020	12/31/3999	No Changes
J9023	INJECTION, AVELUMAB, 10 MG	09/01/2020	12/31/3999	No Changes
J9025	AZACITIDINE INJECTION	09/01/2020	12/31/3999	No Changes
J9027	CLOFARABINE INJECTION	09/01/2020	12/31/3999	No Changes
J9030	BCG LIVE INTRAVESICAL 1MG	09/01/2020	12/31/3999	No Changes
J9032	INJECTION, BELINOSTAT, 10MG	09/01/2020	12/31/3999	No Changes
J9033	BENDAMUSTINE INJECTION	09/01/2020	12/31/3999	No Changes
J9035	BEVACIZUMAB INJECTION	09/01/2020	12/31/3999	No Changes
J9037	INJ BELANTAMAB MAFODONT BLMF	04/01/2021	12/31/3999	No Changes
J9039	INJECTION, BLINATUMOMAB	09/01/2020	12/31/3999	No Changes
J9040	BLEOMYCIN SULFATE INJECTION	09/01/2020	12/31/3999	No Changes
J9041	BORTEZOMIB INJECTION	09/01/2020	12/31/3999	No Changes
J9042	BRENTUXIMAB VEDOTIN INJ	09/01/2020	12/31/3999	No Changes
J9043	CABAZITAXEL INJECTION	09/01/2020	12/31/3999	No Changes
J9044	INJ, BORTEZOMIB, NOS, 0.1 MG	09/01/2020	12/31/3999	No Changes
J9047	INJECTION, CARFILZOMIB, 1 MG	09/01/2020	12/31/3999	No Changes
J9050	CARMUSTINE INJECTION	09/01/2020	12/31/3999	No Changes
J9055	CETUXIMAB INJECTION	09/01/2020	12/31/3999	No Changes
J9065	INJ CLADRIBINE PER 1 MG	09/01/2020	12/31/3999	No Changes
J9070	CYCLOPHOSPHAMIDE 100 MG INJ	09/01/2020	12/31/3999	No Changes
J9071	INJ CYCLOPHOSPHAMD AUROMEDIC	04/01/2022	12/31/3999	No Changes
J9100	CYTARABINE HCL 100 MG INJ	09/01/2020	12/31/3999	No Changes
J9118	INJ. CALASPARGASE PEGOL-MKNL	09/01/2020	12/31/3999	No Changes
J9120	DACTINOMYCIN INJECTION	09/01/2020	12/31/3999	No Changes
J9130	DACARBAZINE 10 MG INJ	09/01/2020	12/31/3999	No Changes
J9145	INJECTION, DARATUMUMAB 10 MG	09/01/2020	12/31/3999	No Changes
J9150	DAUNORUBICIN INJECTION	09/01/2020	12/31/3999	No Changes
J9153	INJ DAUNORUBICIN, CYTARABINE	09/01/2020	12/31/3999	No Changes
J9171	DOCETAXEL INJECTION	09/01/2020	12/31/3999	No Changes
J9173	INJ., DURVALUMAB, 10 MG	09/01/2020	12/31/3999	No Changes
J9176	INJECTION, ELOTUZUMAB, 1MG	09/01/2020	12/31/3999	No Changes
J9177	INJ ENFORT VEDO-EJFV 0.25MG	09/01/2020	12/31/3999	No Changes
J9178	INJ, EPIRUBICIN HCL, 2 MG	09/01/2020	12/31/3999	No Changes
J9179	ERIBULIN MESYLATE INJECTION	09/01/2020	12/31/3999	No Changes
J9181	ETOPOSIDE INJECTION	09/01/2020	12/31/3999	No Changes
J9185	FLUDARABINE PHOSPHATE INJ	09/01/2020	12/31/3999	No Changes
J9190	FLUOROURACIL INJECTION	09/01/2020	12/31/3999	No Changes
J9200	FLOXURIDINE INJECTION	09/01/2020	12/31/3999	No Changes
J9203	GEMTUZUMAB OZOGAMICIN 0.1 MG	09/01/2020	12/31/3999	No Changes
J9204	INJ, MOGAMULIZUMAB-KPKC, 1 MG	09/01/2020	12/31/3999	No Changes
J9205	INJ IRINOTECAN LIPOSOME 1 MG	09/01/2020	12/31/3999	No Changes
J9206	IRINOTECAN INJECTION	09/01/2020	12/31/3999	No Changes
J9207	IXABEPILONE INJECTION	09/01/2020	12/31/3999	No Changes
J9208	IFOSFAMIDE INJECTION	09/01/2020	12/31/3999	No Changes
J9210	INJ., EMAPALUMAB-LZSG, 1 MG	09/01/2020	12/31/3999	No Changes
J9211	IDARUBICIN HCL INJECTION	09/01/2020	12/31/3999	No Changes
J9216	INTERFERON GAMMA 1-B INJ	09/01/2020	12/31/3999	No Changes
J9223	INJ. LURBINECTEDIN, 0.1 MG	01/01/2021	12/31/3999	No Changes
J9227	INJ. ISATUXIMAB-IRFC 10 MG	10/01/2020	12/31/3999	No Changes
J9228	IPILIMUMAB INJECTION	09/01/2020	12/31/3999	No Changes
J9229	INJ INOTUZUMAB OZOGAM 0.1 MG	09/01/2020	12/31/3999	No Changes
J9230	MECHLORETHAMINE HCL INJ	09/01/2020	12/31/3999	No Changes
J9245	INJ MELPHALAN HYDROCHL 50 MG	09/01/2020	12/31/3999	No Changes
J9246	INJ., EVOMELA, 1 MG	09/01/2020	12/31/3999	No Changes
J9250	METHOTREXATE SODIUM INJ	09/01/2020	12/31/3999	No Changes
J9260	METHOTREXATE SODIUM INJ	09/01/2020	12/31/3999	No Changes
J9261	NELARABINE INJECTION	09/01/2020	12/31/3999	No Changes
J9262	INJ, OMACETAXINE MEP, 0.01MG	09/01/2020	12/31/3999	No Changes
J9263	OXALIPLATIN	09/01/2020	12/31/3999	No Changes
J9264	PACLITAXEL PROTEIN BOUND	09/01/2020	12/31/3999	No Changes
J9266	PEGASPARGASE INJECTION	09/01/2020	12/31/3999	No Changes
J9267	PACLITAXEL INJECTION	09/01/2020	12/31/3999	No Changes
J9268	PENTOSTATIN INJECTION	09/01/2020	12/31/3999	No Changes
J9269	INJ. TAGRAXOFUSP-ERZS 10 MCG	09/01/2020	12/31/3999	No Changes
J9271	INJ PEMBROLIZUMAB	09/01/2020	12/31/3999	No Changes
J9273	INJ TISOTU VEDOTIN-TFTV, 1MG	04/01/2022	12/31/3999	No Changes
J9274	INJ, TEBENTAFUSP-TEBN, 1 MCG	10/01/2022	12/31/3999	New
J9280	MITOMYCIN INJECTION	09/01/2020	12/31/3999	No Changes
J9285	INJ, OLARATUMAB, 10 MG	09/01/2020	12/31/3999	No Changes
J9299	INJECTION, NIVOLUMAB	09/01/2020	12/31/3999	No Changes
J9303	PANITUMUMAB INJECTION	09/01/2020	12/31/3999	No Changes
J9305	PEMETREXED INJECTION	09/01/2020	12/31/3999	No Changes
J9307	PRALATREXATE INJECTION	09/01/2020	12/31/3999	No Changes
J9308	INJECTION, RAMUCIRUMAB	09/01/2020	12/31/3999	No Changes
J9309	INJ, POLATUZUMAB VEDOTIN 1MG	09/01/2020	12/31/3999	No Changes
J9312	INJ., RITUXIMAB, 10 MG	09/01/2020	12/31/3999	No Changes
J9313	INJ., LUMOXITI, 0.01 MG	09/01/2020	12/31/3999	No Changes
J9317	SACITUZUMAB GOVITECAN-HZIY	01/01/2021	12/31/3999	No Changes
J9318	INJ ROMIDEPSIN NON-LYO 0.1MG	10/01/2021	12/31/3999	No Changes
J9319	INJ ROMIDEPSIN LYOPHIL 0.1MG	10/01/2021	12/31/3999	No Changes
J9320	STREPTOZOCIN INJECTION	09/01/2020	12/31/3999	No Changes
J9328	TEMOZOLOMIDE INJECTION	09/01/2020	12/31/3999	No Changes
J9331	INJ SIROLIMUS PROT PART 1 MG	07/01/2022	12/31/3999	No Changes
J9332	INJ EFGARTIGIMOD 2MG	07/01/2022	12/31/3999	No Changes
J9340	THIOTEPA INJECTION	09/01/2020	12/31/3999	No Changes
J9348	INJ. NAXITAMAB-GQGK, 1 MG	07/01/2021	12/31/3999	No Changes
J9349	INJ., TAFASITAMAB-CXIX	04/01/2021	12/31/3999	No Changes
J9351	TOPOTECAN INJECTION	09/01/2020	12/31/3999	No Changes
J9352	INJECTION TRABECTEDIN 0.1MG	09/01/2020	12/31/3999	No Changes
J9353	INJ. MARGETUXIMAB-CMKB, 5 MG	07/01/2021	12/31/3999	No Changes
J9354	INJ, ADO-TRASTUZUMAB EMT 1MG	09/01/2020	12/31/3999	No Changes
J9355	INJ TRASTUZUMAB EXCL BIOSIMI	09/01/2020	12/31/3999	No Changes
J9358	INJ FAM-TRASTU DERU-NXKI 1MG	09/01/2020	12/31/3999	No Changes
J9359	INJ LON TESIRIN-LPYL 0.075MG	04/01/2022	12/31/3999	No Changes
J9370	VINCRISTINE SULFATE 1 MG INJ	09/01/2020	12/31/3999	No Changes
J9371	INJ, VINCRISTINE SUL LIP 1MG	09/01/2020	12/31/3999	No Changes
J9390	VINORELBINE TARTRATE INJ	09/01/2020	12/31/3999	No Changes
J9400	INJ, ZIV-AFLIBERCEPT, 1MG	09/01/2020	12/31/3999	No Changes
Q2009	FOSPHENYTOIN INJ PE	09/01/2020	12/31/3999	No Changes
Q2017	TENIPOSIDE, 50 MG	09/01/2020	12/31/3999	No Changes
Q2050	DOXORUBICIN INJ 10MG	09/01/2020	12/31/3999	No Changes
Q4081	EPO ALFA 100 UNITS, ESRD	09/01/2020	12/31/3999	No Changes
Q5101	INJECTION ZAEXIO	09/01/2020	12/31/3999	No Changes
Q5103	INJECTION, INFLECTRA	09/01/2020	12/31/3999	No Changes
Q5104	INJECTION, RENFLEXIS	09/01/2020	12/31/3999	No Changes
Q5105	INJ RETACRIT ESRD ON DIALYSI	09/01/2020	12/31/3999	No Changes
Q5106	INJ RETACRIT NON-ESRD USE	09/01/2020	12/31/3999	No Changes
Q5107	INJ MVASI 10 MG	09/01/2020	12/31/3999	No Changes
Q5108	INJECTION, FULPHILA?	09/01/2020	12/31/3999	No Changes
Q5110	NIVESTYM	09/01/2020	12/31/3999	No Changes
Q5111	INJECTION, UDENYCA 0.5 MG	09/01/2020	12/31/3999	No Changes
Q5112	INJ ONTRUZANT 10 MG	10/01/2020	12/31/3999	No Changes
Q5113	INJ HERZUMA 10 MG	09/01/2020	12/31/3999	No Changes
Q5114	INJ OGIVRI 10 MG	09/01/2020	12/31/3999	No Changes
Q5115	INJ TRUXIMA 10 MG	09/01/2020	12/31/3999	No Changes
Q5116	INJ., TRAZIMERA, 10 MG	09/01/2020	12/31/3999	No Changes
Q5117	INJ., KANJINTI, 10 MG	09/01/2020	12/31/3999	No Changes
Q5118	INJ., ZIRABEV, 10 MG	09/01/2020	12/31/3999	No Changes
Q5119	INJ RUXIENCE, 10 MG	09/01/2020	12/31/3999	No Changes
Q5121	INJ. AVSOLA, 10 MG	01/01/2021	12/31/3999	No Changes
Q5122	INJ, NYVEPRIA	04/01/2021	12/31/3999	No Changes
Q5123	INJ. RIABNI, 10 MG	07/01/2021	12/31/3999	No Changes
90281	HUMAN IG, IM	09/01/2020	01/15/4000	Deleted
90283	HUMAN IG, IV	09/01/2020	01/15/4000	Deleted
90396	VARICELLA-ZOSTER IG, IM	09/01/2020	01/15/4000	Deleted
C9094	INJ, SUTIMLIMAB-JOME, 10 MG	07/01/2022	01/15/4000	Deleted
C9095	INJ, TEBENTAFUSP-TEBN, 1 MCG	07/01/2022	01/15/4000	Deleted
C9096	INJ, RELEUKO, 1 MCG	07/01/2022	01/15/4000	Deleted
J0220	ALGLUCOSIDASE ALFA INJECTION	09/01/2020	01/15/4000	Deleted
J1130	INJ DICLOFENAC SODIUM 0.5MG	09/01/2020	01/15/4000	Deleted
J2941	SOMATROPIN INJECTION	09/01/2020	01/15/4000	Deleted
J3365	UROKINASE 250,000 IU INJ	09/01/2020	01/15/4000	Deleted

If you have any questions, please email TCHP Pharmacy at: TCHPPharmacy@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.