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June 1, 2011 - Revised 12.19.11

3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

2011 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective July 1, 2011 through September 30, 2011

Revised: 12/19/2011

Name of Drug and EXACT Dosage Given MUST be in Block 19 (paper), as an Attachement, or Narrative Field (EMC)

NOTE 1: Payment allowance limits subject to the ASP methodology are based on 1Q11 ASP data.

NOTE 2: Providers should contact their local Medicare contractor processing the claim for the most appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.

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.

** - Carrier Priced

Changes In Bold

DRUG NAME	DOSAGE	Current PAR	Current NON-PAR	Notes
Actemra (see Tocilizumab)
Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	$1.257	$1.194
Alglucosidase Alfa (Myozyme)	1 mg	$14.830	$14.089
Allopurinol Sodium (Aloprim) ICD-9's 274.9 or 790.6 plus the ICD-9 for the neoplasm. Need name of chemotherapy agent causing the elevation of uric acid and a statement as to why patient can not tolerate oral form of the drug.	500 mg/SDV	$333.982	$317.283	(decreased)
Afinitor (see Everolimus)
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.043	$0.041
Antihemophilic Factor (Recomb) Plasma/Albumin-Free (Xyntha)	1 IU			Code for 2011: J7185
Arformoterol Tartrate (Brovana)	15 mcg			Code for 2011: J7605
Arginine Hydrochloride (R-Gene 10)	300 ml	$11.225	$10.664
Arzerra (see Ofatumumab)
** Ascorbic Acid (Vitamin C) Non-covered by Carrier
** Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg / ml	$0.800	$0.760
Atropine Sulfate / Edrophonium Chloride	10 mg	$1.651	$1.568
Avastin (See Bevacizumab)
Aztreonam (Azactam)	500 mg	$15.564	$14.786
** Bacitracin (Bacim)	50,000 U	$10.170	$9.662
Belimumab (Benlysta) Covered ICD-9: 710.0	120 mg SDV	$469.771	$446.282	Effective March 10, 2011
Bendamustine Hydrochloride (Treanda) Covered indications: 204.10 - lymphoid leukemia, chronic, without mention of remission or 204.11 - lymphoid leukemia, chronic, in remission	1 mg			Code for 2011: J9033
Benlysta (see Belimumab)
Berinert (see C1 Esterase Inhibitor)
Bevacizumab (Avastin) CPT 67028 must be on claim or in history; allow if billed with J3490 or J3590 and the ICD-9 requirements from one of the following codes: 115.02, 115.12, 115.92, 362.01 - 362.07 (any), 362.16, 362.35 - 362.37 (any), 362.42, 362.52 or 362.83.	N/A	$60.000	$57.000	Updated ICD-9 Coverage Effective: 01/01/2011 New Unit Price Per Carrier Medical Director Effective: 05/01/2011
Bretylium Tosylate (Bretylol)	5 mg	$0.175	$0.166
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)	0.25 mg	$0.185	$0.176
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.25% - 1 ml	$0.072	$0.068
Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.50% - 1 ml	$0.072	$0.068
Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.75% - 1 ml	$0.072	$0.068
C1 Esterase Inhibitor (Berinert) - For the treatment of acute abdominal or facial attacks of hereditary angioedema in adult and adolescent patients (277.6)	10 units			Code for 2011: J0597
Cabazitaxel (Jevtana®)	1 mg	$135.770	$128.982
Calciferol (see Ergocalciferol D2)
Calcium Chloride	100 mg / ml	$0.145	$0.138
Canakinumab (Ilaris) - For Cryopyrin-associated periodic syndromes	1 mg			Code for 2011: J0638
Capsaicin 8% Patch (Qutenza) - Must be administered under provider supervision.	10 sq cm			Code for 2011: J7335
Cardizem IV (see Diltiazem Hydrochloride)
** Cefamanadole Nafate (Mandol)	1 gm	$8.610	$8.180
** Cefoperazone Sodium (Cefobid)	1 gm	$16.380	$15.561
Cefotetan Disodium (Cefotan)	1 gm	$11.376	$10.807
Certolizumab Pegol (Cimzia)	1 mg			Code for 2011: J0718
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet)	150 mg	$1.064	$1.011
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$10.752	$10.214
Clevidipine Butyrate	1 mg	$6.148	$5.841
Clindamycin Phosphate (Cleocin)	150 mg	$1.645	$1.563
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Collagenase Clostridium Histolyticum (Xiaflex) Covered for Contracture of palmar fascia (Dupuytren’s concracture) ICD-9 728.6.	0.1 mg			Code for 2011: J0775
Copper Sulfate	0.4 mg	$0.098	$0.093
Cosyntropin IV	0.25 mg			Code for 2011: J0833
Cystografin (see Diatrizoate Meglumine)
Dantrolene Sodium	20 mg	$78.800	$74.860
Degarelix (Firmagon)	1 mg			Code for 2011: J9155
Depacon (see Valproate Sodium)
Denileukin Difitox (Ontak) (For 300 mcg, use code J9160)	150 mcg	$595.430	$565.659
Denosumab (Prolia ™ or Xgeva) If Prolia ™, covered ICD-9 = 733.01; if Xgeva, covered ICD-9 = 198.5.	1 mg	$14.510	$13.785
Dexamethasone Intravitreal Implant (Ozurdex) If billed under J3490 or J3590, with CPT code 67028 & 1 of the following ICD-9 combinations: 1) 362.83 plus 362.35 or 362.36; or 2) 362.30	0.1 mg			Code for 2011: J7312
Dextrose 2.5%	2.50%	$7.680	$7.296
Dextrose 5%	5%	$7.860	$7.467
Dextrose 10%	500 ml	$10.000	$9.500
Dextrose 50%	50 ml	$0.101	$0.096
** Dextrose / Nitroglycerin 5%-20 mg/ 100 ml/250 ml	20 mg/100 ml/250 ml	$6.320	$6.004
** Dextrose 5% / Sodium Chloride	1000 ml	$11.220	$10.659
Diatrizoate Meglumine (Cystografin)	10 ml	$2.10	$2.00	Effective 05/01/2011
Diltiazem Hydrochloride (Cardizem IV)	5 mg	$0.152	$0.144
Diprivan (see Propofol)
Doripenem (Doribax)	10 mg			Code for 2011: J1267
Doxapram Hydrochloride (Dopram)	20 mg	$1.670	$1.587
Doxycycline Hyclate	100 mg	$12.113	$11.507
Ecallantide (Kalbitor) Covered Indications - 277.6 (accute attack of hereditary angioedema)	1 mg			Code for 2011: J1290
Eculizumab (Soliris)	10 mg			Code for 2011: J1300
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	$2.420	$2.299	(increased)
Elaprase (see Idursulfase)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)	1.25 mg	$1.805	$1.715
Eovist (see Gadoxetate Disodium)
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office	500,000 IU/ 1ml	$29.840	$28.348
Eribulin Mesylate (Halaven) - Covered ICD-9's = 174.0 - 174.9	1 mg	$900.269	$855.256
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 = 427.89 (Dosage change from 100 mg to 10 mg.)	10 mg	$0.679	$0.645
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.	20 MG	$2.140	$2.033
Estradiol	1 gram	$13.300	$12.635
** Estradiol Pellets	Per Pellet	Invoice	Invoice
Ethacrynate Sodium (Edecrin Sodium)	50 mg	$19.040	$18.088
** Ethiodized Oil (Ethiodol)	1 ml	$8.060	$7.657
Etomidate (Amidate)	2 mg	$0.502	$0.477
Everolimus (Afinitor / Zortress) - Non-Covered; Oral drug considered as self-administered.
Famotidine (Pepcid)	10 mg	$0.361	$0.343
Ferumoxytol (Feraheme)	1 mg			Codes for 2011: Q0138 (non-esrd) & Q0139 (esrd)
Fibrinogen Concentrate Human (RiaSTAP)				Code for 2011: J1680
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Fludarabine phosphate, oral - Not Covered by Part B	10 mg			Code for 2011: J8562
Flumazenil (Mazicon, Romazicon)	0.1 mg	$1.342	$1.275
Flumazenil (Mazicon, Romazicon)	0.5 mg	$42.830	$40.689
Folic Acid	5 mg	$1.769	$1.681
Folotyn (see Pralatrexate)
Fosaprepitant Dimeglumine (Emend) Allowed when billed on the same day as chemotherapy.	1 mg			Code for 2011: J1453
Fospropofol Disodium injection (Lusedra)	35 mg	$1.011	$0.960
Gadoxetate Disodium (Eovist)	1 ml			Code for 2011: A9581
Gammaplex (see Human Immune Globulin Intravenous)
Glycopyrrolate (Robinul)	0.2 mg	$0.212	$0.201
Graftjacket Gel	1 cc			Code for 2011: Q4113
Halaven (see Eribulin Mesylate)
** Heparin Sodium	100 units	$0.032	$0.030
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm	$23.040	$21.888
Hexaminolevulinate Hydrochloride - Covered for ICD-9's 188.0 through 188.9	100 mg, per study dose	$623.280	$592.116
Hizentra (see Immune Globulin Subcutaneous)
Human Immune Globulin Intravenous (Gammaplex)	500 mg	$37.919	$36.023
Hydroxocobalamin - Covered when billed with J9305.	1000 mcg/ml	$1.212	$1.151	Effective 06/01/2011
Hylan G-F 20 (Synvisc-One)	48 mg			Code for 2011: J7325
Idursulfase (Elaprase)	1 mg			Code for 2011: J1743
Ilaris (see Canakinumab)
Immune Globulin Subcutaneous (Hizentra)	100 mg			Code for 2011: J0597
** Inamrinone Lactate	5 mg	$4.050	$3.848
IncobotulinumtoxinA (Xeomin) - Covered for the treatment of Genetic torsion dystonia (333.6) and Blepharospasm (333.81)	1 Unit			New Code for 2011: Q2040
INTEGRA™ Bilayer Matrix Wound Dressing - Covered Indications = 757.39, 941.20-941.21, 941.24-941.31, 941.34-941.41, 941.44-941.51, 941.54-941.59, 942.20-942.59, 943.20-943.59, 944.20-944.58, 945.20-945.59, 946.2-946.5, 948.00-948.99	1 sq cm	$20.743	$19.706
Invega® Sustenna® (see Paliperidone Palmitate injection)
Ipilimumab (Yervoy) - Covered for unresectable or metastatic melanoma.	5 mg	Invoice	Invoice	Effective 04/01/2011
Isoproterenol Hydrochloride (Isuprel)	0.2 mg	$2.250	$2.138
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
Isuprel (see Isoproterenol Hydrochloride)
Ixabepilone (Ixempra) Covered for metastatic or locally advanced breast cancer (ICD-9 codes 174.0 - 175.9)	1 mg			Code for 2011: J9207
Jevtana® (see Cabazitaxel)
Kalbitor (see Ecallantide)
Kenalog (see Triamcinolone Acetonide)
Keppra intraveneous (see Levetiracetam)
Ketamine Hydrochloride (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.	10 mg	$0.067	$0.064
Krystexxa (see Pegloticase)
Labetalol Hydrochloride (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses.	5 mg	$0.081	$0.077
Lanreotide (Somatuline Depot)	1 mg			Code for 2011: J1930
Levetiracetam (Keppra intraveneous)	10 mg			Code for 2011: J1953
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76003, 95990, or 96530. Not payable separately when billed with any other procedures	2.5 mg/ml	$0.310	$0.295
** Levophed Bitartrate (see Norepinephrine Bitartrate)
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug.	0.5 mg	$62.010	$58.910
Lexiscan (see Regadenoson)
Lidocaine - Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77033, 95990, or 96530. Not payable when billed with any other procedure.	1 ml	$0.143	$0.136
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Lusedra (see Fospropofol Disodium injection)
Mandol (see Cefamanadole Nafate)
Mazicon (see Flumazenil)
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	$0.153	$0.145
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered for ICD-9's= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0-567.9, 599.0-599.9, 615.0-615.9.	500 mg	$1.196	$1.136
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium	50 mg	$2.151	$2.043
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	$8.058	$7.655
Nalmefene Hydrochloride (Revex)	10 mcg	$0.276	$0.262
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency situations.	5 mg	$0.404	$0.384
Nodolo & Tusal (see Sodium Thiosalicylate)
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow in emergency situations.	1 mg	$2.161	$2.053
Norcuron (see Vecuronium Bromide)
Normal Saline (Sterile Water)	50 ml	$1.430	$1.359
Normodyne (see Labetalol Hydrochloride)
Nplate™ (see Romiplostim)
Ofatumumab (Arzerra) Covered indications - 204.10 or 204.12	10 mg			Code for 2011: J9302
Ofloxacin (Floxin IV), 20 mg		Invoice	Invoice
Olanzapine long -acting intramuscular injection Covered indications = 295.00 - 295.95 or 296.40 - 296.66 when administered in the physicians office.	1 mg			Code for 2011: J2358
Olanzapine short -acting intramuscular injection (Zyprexa IM) Covered indications = 295.01 - 295.84 when administered in the physicians office.	0.5 mg	$1.637	$1.555
Ontak (see Denileukin Difitox)
Optison		Invoice	Invoice
** Oxychlorosene Sodium (Clorpactin WCS-90)	1 gm	$1.850	$1.758
Ozurdex (see Dexamethasone Intravitreal Implant)
Paliperidone Palmitate injection (Invega® Sustenna®) Covered indications: 295.00-295.95, 296.40-296.46, 296.50-296.56, or 296.60-296.66	1 mg			Code for 2011: J2426
Panitumumab (Vectibix) Covered indications-153.0-154.8	10 mg			Code for 2011: J9303
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	$4.511	$4.285
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) Covered indication 070.54 when administered in the office.	180mcg/ml	$480.273	$456.259
Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication 070.54 when administered in the office.	50 mcg	$320.610	$304.580
** Peginterferon Alfa-2B, 80mcg	80 mcg	$336.600	$319.770
** Peginterferon Alfa-2B, 120mcg	120 mcg	$353.460	$335.787
** Peginterferon Alfa-2B, 150mcg	150 mcg	$371.120	$352.564
Pegloticase (Krystexxa) When billed with J3490 or J3590, covered for chronic gout, ICD-9's 274.00 through 274.03	8 mg SDV	Invoice	Invoice
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered
Pepcid (see Famotidine)
Potassium Acetate	2 meq	$0.027	$0.026
Potassium Phosphate	3 mmol	$0.043	$0.041
Pralatrexate (Folotyn) - Covered indications: 202.70 - 202.78	1 mg			Code for 2011: J9307
Prednisolone Acetate	1 ml			Code for 2010: J2650
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Prolia ™ (see Denosumab)
Propofol (Diprivan)	10 mg	$0.122	$0.116
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
** R-Gene 10 (see Arginine Hcl.)
Ranibizumab Injection (Lucentis)	1 mcg			Code for 2011: J2778
Regadenoson (Lexiscan)	0.1 mg			Code for 2011: J2785
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate Human)
Rifampin	600 mg	$37.015	$35.164
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Romidepsin (Istodax) Covered indications: 202.70 - 202.78	1 mg			Code for 2011: J9315
Romiplostim (Nplate™)	10 mcg			Code for 2011: J2796
Sarracenia Purpura Non-covered by Carrier
Secretin (SecreFlo) Used in secretin stimulation testing	1 mcg			Code for 2011: J2850
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sipuleucel-T (Provenge) ICD-9 = 185	Per infusion (minimum 50 million cells)			New Code for 2011: Q2043
Sodium Acetate	2 meq	$0.022	$0.021
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	$0.122	$0.116
Sodium Chloride, Hypertonic	250 cc	$0.835	$0.793
** Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.155	$0.147
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)	5 cc	$0.052	$0.049
Stelara (see Ustekinumab)
Sterile Saline / Water	1000 ml	$5.640	$5.358
** Sterile Saline / Water, 1000 ml	50mcg/ml	$9.810	$9.320
** Sufentanil Citrate (Sufenta) Separate payment allowed when billed with 62310, 62311, 62318, 62319, 76005, 95990, or 96530. If billed with any other procedures, it will be considered part of the procedure and separate payment will not be allowed.
Sulfamethoxazole/Trimethoprim (SMZ-TMP) Documentation as to why the patient needs to be on IV infusion instead of oral medication, must be in block 19 or as an attachment for paper claims or in the notepad for EMC claims.	400 - 80 mg	$1.309	$1.244
SurgiMend	0.5 sq cm	$11.260	$10.697
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
Telavancin Injection (VIBATIV™)	10 mg			Code for 2011: J3095
Temsirolimus (Torisel) Covered indication is for the treatment of advanced renal cell carcinoma (189.0 Malignant neoplasm of kidney, except pelvis).	1 mg			Code for 2011: J9330
Tenormin (see Atenolol)
Tensilon (see Edrophonium Chloride)
Testosterone	37.5 mg	$0.110	$0.105
** Testosterone Pellets (Testopel)	Per Pellet	Invoice	Invoice
Tetanus Toxoid (use codes 90702, 90703, or 90718)
Tetracycline		Invoice	Invoice
Tocilizumab (Actemra) Covered Indications: 714.0, 714.1 or 714.2.	1 mg			Code for 2011: J3262
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Treprostinil inhalation (Tyvaso) - If administered in-office, considered part of service performed. If administered at-home, not covered by Part B.	1.74 mg			Code for 2011: J7686
Triamcinolone Acetonide, Preservative Free	1 mg			Code for 2011: J3300
Triamcinolone Acetonide (Kenalog)	10 mg			Code for 2011: J3301
Truxton (see Prednisolone Acetate)
Tyvaso (see Treprostinil inhalation)
Ustekinumab (Stelara) - For the treatment of adults (18+) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (696.1)	1 mg			Code for 2011: J3357
Vaccinia IVIG (see Human Immune Globulin Intravenous)
Valproate Sodium (Depacon) IV, Covered ICD9's = 345.00 - 345.91, Allowed when administered IV, in the physician's office. (Dosage change from 500 mg to 100 mg)	100 mg	$0.558	$0.530
Vasopressin	20 units	$1.578	$1.499
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)	1 mg	$0.408	$0.388
Velaglucerase alfa for injection (VPRIV™)	100 units			Code for 2011: J3385
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	$3.167	$3.009
VIBATIV™ (see Telavancin Injection)
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3 ml	$0.930	$0.884
** Vitamin C (see Ascorbic Acid) Non-covered by Carrier
Vivaglobin (see Immune Globulin Subcutaneous)
VPRIV™ (see Velaglucerase alfa for injection)
Wilate (Human coagulation factor VIII (FVIII) and von Willebrand factor (VWF) powder and solvent for solution for injection) Covered ICD-9: 286.4	1 IU VWF:RCO			New Code for 2011: Q2041
Xeomin (see IncobotulinumtoxinA)
Xgeva (see Denosumab)
Xiaflex (see Collagenase Clostridum Histolyticum)
Xyntha (see Antihemophilic Factor (Recomb) Plasma/Albumin-Free)
Yervoy (see Ipilimumab)
Zortress (see Everolimus)
Zyprexa IM (see Olanzapine)
HOCM <= 149 MG/ML	1 ml	$0.041	$0.039
HOCM 200 - 249 MG/ML	1 ml	$0.093	$0.088
HOCM 250 - 299 MG/ML	1 ml	$0.100	$0.095
HOCM 300 - 349 MG/ML	1 ml	$0.104	$0.099
HOCM 350 - 399 MG/ML	1 ml	$0.107	$0.102
HOCM >= 400 MG/ML	1 ml	$0.191	$0.181