CMS Pub. 100-04, ch. 17, § 80.2.1

The physician/supplier bills for these drugs with the ASC X12 837 professional claim format, or if

approved, with the paper form CMS-1500. The facility bills with the ASC X12 837 institutional claim

format, or if approved, with the paper Form CMS-1450. The following HCPCS codes are assigned:

Code Description

J8501 APREPITANT, oral, 5 mg (Note: HCPCS code is effective January 1,

2005, but coverage for aprepitant is effective April 4, 2005. Aprepitant is

only covered in combination with a 5HT3 antagonist, and dexamethasone

for beneficiaries who have received one or more of the specified anti-cancer chemotherapeutic agents.)

Q0161 CHLORPROMAZINE HYDROCHLORIDE 5mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0162 ONDANSETRON 1mg, oral, FDA-approved prescription anti-emetic, for

use as a complete therapeutic substitute for an IV anti-emetic at the time of

chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0163 DIPHENHYDRAMINE HYDROCHLORIDE, 50mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at time of chemotherapy treatment not to exceed a 48-hour

dosage regimen.

Q0164 PROCHLORPERAZINE MALEATE, 5mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0165 PROCHLORPERAZINE MALEATE, 10mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0166 GRANISETRON HYDROCHLORIDE, 1mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen.

Q0167 DRONABINOL2.5mg, oral, FDA-approved prescription anti-emetic, for

use as a complete therapeutic substitute for an IV anti-emetic at the time of

chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0168 RONABINO 5mg, oral, FDA-approved prescription anti-emetic, for use as

a complete therapeutic substitute for an IV anti-emetic at the time of

chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0169 PROMETHAZINE HYDROCHLORIDE, 12.5mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0170 PROMETHAZINE HYDROCHLORIDE, 25mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Code Description

Q0171 CHLORPROMAZINE HYDROCHLORIDE, 10mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0172 CHLORPROMAZINE HYDROCHLORIDE, 25mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0173 TRIMETHOBENZAMIDE HYDROCHLORIDE, 250mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic

substitute for an IV anti-emetic at the time of chemotherapy treatment, not

to exceed a 48-hour dosage regimen.

Q0174 THIETHYLPERAZINE MALEATE, 10mg, oral, FDA-approved

prescription anti-emetic, for use as a complete therapeutic substitute for an

IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0175 PERPHENAZINE 4mg, oral, FDA-approved prescription anti-emetic, for

use as a complete therapeutic substitute for an IV anti-emetic at the time of

chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0176 PERPHENAZINE, 8mg, oral, FDA-approved prescription anti-emetic, for

use as a complete therapeutic substitute for an IV anti-emetic at the time of

chemotherapy treatment, not to exceed a 48-hours dosage regimen.

Q0177 HYDROXYZINE PAMOATE, 25mg, oral, FDA-approved prescription

anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour

dosage regimen.

Q0178 HYDROXYZINE PAMOATE, 50mg, oral, FDA-approved prescription

anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour

dosage regimen.

Q0179 ONDANSETRON mg, oral, FDA-approved prescription anti-emetic, for

use as a complete therapeutic substitute for an IV anti-emetic at the time of

chemotherapy treatment, not to exceed a 48-hour dosage regimen.

Q0180 DOLASETRON MESYLATE, 100mg, oral, FDA-approved prescription

anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour

dosage regimen.

Q0181 UNSPECIFIED ORAL DOSAGE FORM, FDA-approved prescription

anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour

dosage regimen.

NOTE: The 24-hour maximum drug supply limitation on dispensing, for HCPCS Codes Q0166 and

Q0180, has been established to bring the Medicare benefit as it applies to these two therapeutic entities

in conformity with the “Indications and Usage” section of currently FDA-approved product labeling for

each affected drug product.