License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective January 1, 2017 through March 31, 2017

Revised: 12.19.17

Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link: http://www.cms.gov/McrPartBDrugAvgSalesPrice/01a18_2011ASPFiles.asp

Note 2: Payment allowance limits subject to the ASP methodology are based on 2Q12 ASP data.

Note 3: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug.

Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor processing the claim.

Note 4: ** - Carrier-priced

HCPCS Code	Short Description	HCPCS Code Dosage	Payment Limit	Notes
90396**	varicella-zoster immune globulin	125 U / 1.25 ML	Invoice
90396**	varicella-zoster immune globulin	625 U / 6.25 ML	Invoice
90736**	Zostavax	Per Carrier Medical Director not covered by Part B.		Added January 2013
A9587**	Gallium ga-68, dotatate, diagnostic,	0.1 Millicurie	3604.00	Added January 2017
A9588**	Fluciclovine f-18, diagnostic	1 Millicurie	3895.50	Added January 2017
A9606**	Radium Ra 223 dichloride (Xofigo)	MicroCurie	128.21	Eff:1/1/2015 / Pricing change 01/11/16
J0200**	Alatrofloxacin mesylate	100 MG	Invoice
J0270**	Alprostadil, 1.25 MCG	Considered self-administered.
J0275**	Alprostadil Urethral Suppository	Considered self-administered.
J0282**	Amiodarone Hcl	30 MG	0.452
J0380**	metaraminol bitartrate, inj	10 MG	Invoice
J0390**	Chloroquine injection	250 MG	Invoice
J0395**	Arbutamine HCl injection	1 MG	Invoice
J0520**	Bethanechol chloride inject	Oral drug considered part of procedure in physician's office.
J0596**	C-1 esterase inhibitor(Ruconest)	10 Units	27.573
J0620**	Calcium glycerophosphate/Calcium lactate	10 ML	Invoice
J0695**	Ceftolozane 50mg and Tazobactam 25mg	50mg/25mg	Invoice
J0714**	Ceftazidime and Avibactam	0.5g/0.125g	Invoice
J0715**	Ceftizoxime sodium / 500 MG	500 MG	Invoice
J1130**	Diclofenac sodium (Dyloject)	0.5 mg	$0.223	Added 05/2017
J1324**	Enfuvirtide	Considered self-administered.
J1443**	Ferric Pyrophosphate Citrate Sol (Triferic)	0.1mg	Invoice
J1590**	Gatifloxacin injection	Considered self-administered.
J1595**	Injection glatiramer acetate	Considered self-administered.
J1675**	Histrelin Acetate	Considered self-administered.
J1680**	fibrinogen concentrate human	100 MG	$103.550
J1700**	Hydrocortisone acetate inj	25 MG	$0.360
J1710**	Hydrocortisone sodium ph inj	50 MG	Invoice
J1725**	Hydroxyprogesterone Caporate	1 MG	Invoice
J1826**	Interferon beta-1a / 30 mcg (Avonex)	30 mcg	$ 1,542.565	Added August 2016
J1830**	Interferon beta-1b / .25 MG	Not covered by carrier.
J1833**	Isavuconazonium Sulfate (Cresemba)	1 MG	0.68
J1890**	Cephalothin sodium injection	1 G	Invoice
J1960**	Levorphanol tartrate	2 MG	$3.765
J1990**	Chlordiazepoxide injection	100 MG	Invoice
J2170**	Mecasermin	Considered self-administered.
J2182**	Mepolizumab (Nucala)	1 MG	27.295	Added January 2017
J2265**	Minocycline Hydrochloride	Considered self-administered.
J2278KD**	Ziconotide injection	1 MCG	Invoice
J2320**	Nandrolone decanoate 50 MG	50 MG	$4.452
J2502**	Pasireotide	1 MG	$197.867	Added January 2016
J2513**	Pentastarch 10% solution	10%	Invoice
J2547**	Peramivir	1 MG	$1.678
J2650**	Prednisolone acetate	1 ML	$0.342
J2670**	Tolazoline hcl injection	25 MG	Invoice
J2786**	Reslizumab (Cinqair)	1 MG	$8.851	Added January 2017
J2840**	Seblipase alfa (Kanuma)	1 MG	$530.000	Added January 2017
J2860**	Siltuximab	10 MG	$90.947
J2940**	Somatrem injection	Considered self-administered.
J2941**	Somatropin injection	Considered self-administered.
J2950**	Promazine HCL (Sparine)	25MG	Invoice
J3030**	Sumatriptan Succinate	Considered self-administered.
J3110**	Teriparatide injection	Considered self-administered.
J3145**	Testosterone Undecanoate(Aveed)	1 MG	$1.166	Added January 2015
J3265**	Injection torsemide 10 mg/ml	10 MG	$4.000
J3280**	Thiethylperazine maleate, inj	10 MG	Invoice
J3310**	Perphenazine	5 MG	$1.476	Added July 2015
J7121**	5% Dextrose in lactated ringers	1000 CC	Invoice
J7130**	Hypertonic saline solution	20 CC	Invoice
J7175**	Factor X human (Coagdex) NOTE:0.209 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee	1 IU	$8.827	Added January 2017
J7179**	Von Willebrand factor (recombinant), (Vonvendi) NOTE:0.209 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee	1 IU	$2.189	Added January 2017
J7188**	Factor VIII (Obizur) NOTE:0.202 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee	1 IU	$5.470	Updated pricing 08/2017
J7191**	Factor viii (porcine)	1 IU	Invoice
J7202**	Factor ix, albumin fusion protein, (recombinant),(Idelvion) NOTE:0.209 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee	1 IU	$4.714	Added January 2017
J7207**	Factor viii, (antihemophlic factor, recombinant, (pegylated), Adynovate NOTE:0.209 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee	1 IU	$2.189	Added January 2017
J7209**	Factor viii (antihemophilic factor, recombinant), (Nuwiq) NOTE:0.209 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee	1 IU	$2.000	Added January 2017
J7322**	Hyaluronic acid (Hymovis)	1 MG	$17.667	Added January 2017
J7328**	Hyaluronan or derivative, gel-syn	0.1 MG	$2.177
J7340**	Carbidopa 5mg/Levodopa 20mg	5mg/20mg	Invoice
J7604**	Acetylcystein	Considered part of procedure in physician's office.
J7622**	Beclomethasone inhalation sol	Considered part of procedure in physician's office.
J7624**	Betamethasone inhalation sol	Considered part of procedure in physician's office.
J7628**	Bitolterol mes inhal sol con	Considered part of procedure in physician's office.
J7629**	Bitolterol mes inh sol u d	Considered part of procedure in physician's office.
J7633**	Budesonide concentrated sol	Considered part of procedure in physician's office.
J7641**	Flunisolide, inhalation sol	Considered part of procedure in physician's office.
J7648**	Isoetharine hcl inh sol con	Considered part of procedure in physician's office.
J7649**	Isoetharine hcl inh sol u d	Considered part of procedure in physician's office.
J7658**	Isoproterenol hcl inh sol con	Considered part of procedure in physician's office.
J7659**	Isoproterenol hcl inh sol ud	Considered part of procedure in physician's office.
J7668**	Metaproterenol inh sol con	Considered part of procedure in physician's office.
J7680**	Terbutaline so4 inh sol con	Considered part of procedure in physician's office.
J7681**	Terbutaline so4 inh sol u d	Considered part of procedure in physician's office.
J7683**	Triamcinolone inh sol con	Considered part of procedure in physician's office.
J7684**	Triamcinolone inh sol u d	Considered part of procedure in physician's office.
J8561**	Everolimus, 0.25 MG	Should be billed to DMAC.
J9039**	Blinatumomab	1 MCG	96.265	Added January 2016
J9165**	Diethylstilbestrol diphosphate injection	250 MG	Invoice
J9213**	Interferon alfa-2a inj	3 MIL UNITS	Invoice
J9215**	Interferon, alfa-n3	250,000 IU	$23.834
J9262**	Omacetaxine Mepesuccinate(Synribo)	0.01 MG	$2.529
J9270**	Plicamycin (mithramycin) inj	2.5 MG	Invoice
J9600**	Porfimer Sodium injection	75 MG	$ 20,410.406
Q0174**	Thiethylperazine maleate, 10mg	Should be billed to DMAC.
Q0179**	Ondansetron hcl 9 mg oral	Should be billed to DMAC.
Q0181**	Unspecified oral dosage form, FDA approved presription anti-emetic	Should be billed to DMAC.
Q2026**	Radiesse injection	0.1 ML	Invoice
Q2028**	Sculptra	0.5 MG	Invoice
Q2034**	Agriflu	0.05 ML	Invoice
Q2036**	Flulaval Quadrivalent 3 yrs & >, im	0.05 ML	$19.174	Added November 2016
Q2039**	Not Otherwise Classified flu vacc, 3 yrs & >, im	0.5 ML	Invoice	If drug has a assigned code you must use the correct code
Q4105**	Integra Omnigraft	1 sq cm	$54.082	Added 10/17
Q4110**	PriMatrix Dermal Repair Scaffold (PriMatrix) and PriMatrix Antimicrobial Dermal Repair Scaffold (PriMatrix AG)	1 sq cm	$33.668	Added 10/17
Q4118**	Matristem Micromatrix	1 MG	$2.433
Q4119**	Matristem Micromatrix	1 SQ CM	$2.470
Q4122**	Dermacell	1 SQ CM	Invoice
Q4124**	Oasis Ultra Tri-Layer Wound Matrix	1 SQ CM	$11.400
Q4125**	Arthroflex	1 SQ CM	Invoice
Q4126**	Memoderm	1 SQ CM	Invoice
Q4127**	Talymed	1 SQ CM	Invoice
Q4128**	Flex HD or Allopatch HD	1 SQ CM	Invoice
Q4129**	Unite Biomatrix	1 SQ CM	Invoice
Q4130**	Strattice TM	1 SQ CM	Invoice
Q4132**	Grafix core	1 SQ CM	158.223	Updated 06/2016
Q4133**	Grafix prime	1 SQ CM	158.223	Updated 06/2016
Q4137**	Amnioexcel or Biodexcel	1 SQ CM	Invoice
Q4138**	Biodfence dryflex	1 SQ CM	Invoice
Q4139*	Amniomatrix or Biodmatrix	1 CC	Invoice
Q4140**	Biodfence	1 SQ CM	Invoice
Q4141**	Alloskin ac	1 SQ CM	Invoice
Q4142**	Xcm Biologic Tissue Matrix	1 SQ CM	Invoice
Q4143**	Repriza	1 SQ CM	Invoice
Q4145**	Epifix	1 MG	Invoice
Q4146**	Tensix	1 SQ CM	Invoice
Q4147**	Architect Extracellular Matrix	1 SQ CM	Invoice
Q4148**	Neox 1k	1 SQ CM	Invoice
Q4149**	Excellagen	0.1 CC	34.200
Q4152**	Dermapure	1 SQ CM	88.113
Q4161**	Bio-connekt	1 SQ CM	Invoice	Added January 2016
Q4162**	Amnio bio, woundex flow	1 SQ CM	Invoice	Added January 2016
Q4163**	Amnio bio, woundex	1 SQ CM	Invoice	Added January 2016
Q4164**	Helicoll	1 SQ CM	Invoice	Added January 2016
Q4165**	Keramatrix	1 SQ CM	Invoice	Added January 2016
Q4172**	PuraPly or PuraPly am	1 SQ CM	118.720	Added January 2017
Q9953**	Iron Based Magnetic Resonance Contrast Agent	1 ML	Invoice
Q9955**	Inj perflexane lip micros, ml	1 ML	Invoice
Q9980**	Genvisc	1 MG	$9.765	Added January 2016

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective January 1, 2017 through March 31, 2017

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