HCPCS Code Section: HCPCS C Codes

Injection, ceftolozane 50 mg and tazobactam 25 mg Short Description: Inj, ceftolozane/tazobactam Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: April 1, …

Injection, peramivir, 1 mg Short Description: Injection, peramivir Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: April 1, 2015 Effective Date: January …

Injection, fluocinolone acetonide intravitreal implant, 0.01 mg Short Description: Fluocinolone acetonide implt Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: April 1, …

Injection, blinatumomab, 1 mcg Short Description: Inj, blinatumomab Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: April 1, 2015 Effective Date: January …

Netupitant 300 mg and palonosetron 0.5 mg, oral Short Description: Oral netupitant palonosetron Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: April …

Injection, phenylephrine and ketorolac, 4 ml vial Short Description: Inj, phenylephrine ketorolac Coverage Code: Special coverage instructions apply Action Code: Discontinue procedure or modifier code Date Added: January 1, …

Injection, tedizolid phosphate, 1 mg Short Description: Inj, tedizolid phosphate Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: January 1, 2015 Effective …

Injection, c-1 esterase inhibitor (recombinant), ruconest, 10 units Short Description: C-1 esterase, ruconest Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: April …

Injection, oritavancin, 10 mg Short Description: Injection, oritavancin Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: January 1, 2015 Effective Date: January …

Injection, dalbavancin, 10 mg Short Description: Injection, dalbavancin Coverage Code: Special coverage instructions apply Action Code: No maintenance for this code Date Added: January 1, 2015 Effective Date: January …