Type of Service (TOS) Indicator G: Immunosuppressive Drugs

Special Considerations/Exceptions
For injection codes with more than one possible TOS designation, use the following guidelines when assigning the TOS:
When the choice is G or 1:

HCPCS codes

J0215  Injection, alefacept, 0.5 mg  
J0480  Injection, basiliximab, 20 mg  
J1675  Injection, histrelin acetate, 10 micrograms  
J2920  Injection, methylprednisolone sodium succinate, up to 40 mg  
J2930  Injection, methylprednisolone sodium succinate, up to 125 mg  
J7500  Azathioprine, oral, 50 mg  
J7501  Azathioprine, parenteral, 100 mg  
J7502  Cyclosporine, oral, 100 mg  
J7503  Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg  
J7504  Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg  
J7505  Muromonab-cd3, parenteral, 5 mg  
J7506  Prednisone, oral, per 5 mg  
J7507  Tacrolimus, immediate release, oral, 1 mg  
J7508  Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg  
J7509  Methylprednisolone oral, per 4 mg  
J7510  Prednisolone oral, per 5 mg  
J7511  Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg  
J7512  Prednisone, immediate release or delayed release, oral, 1 mg  
J7513  Daclizumab, parenteral, 25 mg  
J7515  Cyclosporine, oral, 25 mg  
J7516  Cyclosporin, parenteral, 250 mg  
J7517  Mycophenolate mofetil, oral, 250 mg  
J7518  Mycophenolic acid, oral, 180 mg  
J7520  Sirolimus, oral, 1 mg  
J7525  Tacrolimus, parenteral, 5 mg  
J7527  Everolimus, oral, 0.25 mg  
J7599  Immunosuppressive drug, not otherwise classified  
J8501  Aprepitant, oral, 5 mg  
J8530  Cyclophosphamide; oral, 25 mg  
J8561  Everolimus, oral, 0.25 mg  
J8610  Methotrexate; oral, 2.5 mg  
J8650  Nabilone, oral, 1 mg  
J9213  Injection, interferon, alfa-2a, recombinant, 3 million units  
J9214  Injection, interferon, alfa-2b, recombinant, 1 million units  
J9215  Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iu  
J9216  Injection, interferon, gamma 1-b, 3 million units  
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