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Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective July 1, 2018 through September 30, 2018

Revised: 08.13.19

Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.htmlExternal Website

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  
90630 IIV4 Vacc no prsv 3 yrs+id 0.1 ml Invoice No new pricing available for the 2018-2019 flu season.
90654 Flu vaccine, intradermal, no preserv Non FDA Approved No new pricing available for the 2018-2019 flu season.
90655 Flu vaccine no preserv 6-35m, im 0.25 ML Invoice No new pricing available for the 2018-2019 flu season.
90657 Flu vaccine, 6-35 mo, im 0.25 ML Invoice No new pricing available for the 2018-2019 flu season.
90661 Flu vaccine, derived from cell cultures, subunit 45 mcg/0.5 ML Invoice No new pricing available for the 2018-2019 flu season.
90672 Flu vaccine 4 valent nasal 0.2 ml Invoice No new pricing available for the 2018-2019 flu season.
90673 Flublok, trivalent 18 & > 0.5 ml Invoice No new pricing available for the 2018-2019 flu season.
90736** Zostavax (live/attenuated form ) Per Carrier Medical Director not covered by Part B. Added January 2013
90750** Zostavax (recombinant form) Per Carrier Medical Director not covered by Part B. Added February 2018
A9587** Gallium ga-68, dotatate, diagnostic, .1 Mci. 66.74 Updated pricing 10/2017
A9588** Fluciclovine f-18, diagnostic Per Mci Invoice Changed pricing to invoice
A9606** Radium Ra 223 dichloride (Xofigo) MicroCurie 139.761 Eff:1/1/2015 / Pricing change EFF 10/01/17 / price change 7/2018
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 0.424 Updated August 2019
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.  
J0565** Bezlotoxumab (Zinplava) 10 mg 40.28 Added January 2018
J0584** Burosumab-twza (Crysvita) 1 MG $ 360.400 Added January 2019
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
J1301** Edaravone (Radicava) 1 MG $ 19.570 Added January 2019
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  
J1726** Hydroxyprogesterone Caproate (Makena) 10 MG $ 32.408 Added January 2018
J1746** Ibalizumab-uiyk (Trogarzo) 10 MG $ 60.306 Added January 2019
J1826** Interferon beta-1a / 30 mcg (Avonex) 30 mcg $ 1,542.565  
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 29.522 Added January 2017/ Updated pricing 07/2017
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  
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
J2797** Rolapitant (Varubi) 0.5 MG $ 10.152 Added January 2019
J2840** Seblipase alfa (Kanuma) 1 MG $ 541.130 Added January 2017 / Updated August 2019
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  
J3245** Tildrakizumab-asmn (Ilumya) 1 MG $ 140.514 Added February 2019
J3265** Injection torsemide 10 mg/ml 10 MG $ 4.000  
J3280** Thiethylperazine maleate, inj 10 MG Invoice  
J3310** Perphenazine 5 MG $ 1.476  
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
J7210** Antihemophilic factor (recombinant) single chain (AFSTYLA) NOTE:0.215 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee 1 IU $ 1.960 Added January 2018
J7211** Antihemophilic factor viii (recombinant) Kovaltry NOTE:0.215 per unit has been added based on the IOM 100-04, Chapter 17, Section 80.4.1 Clotting Factor Furnishing Fee 1 IU $ 2.017 Added January 2018
J7296** Levonorgestrel releasing intrauterine contraceptive system, (Kyleena) 19.5 MG $ 963.508 Added January 2018
J7315** Mitomycin - ophthalmic 0.2 mg topical solution Considered part of procedure Added September 2018
J7318** Hyaluronic acid (Durolane) 3 ML $ 17.225 Added January 2019
J7322** Hyaluronic acid (Hymovis) 1 MG $ 19.257 Added January 2017/ Updated pricing 07/2017
J7326** Hyaluronate sodium (Gel-One) 30mg/3ml $ 1,057.880 Added January 2019
J7328** Hyaluronan or derivative, gel-syn 0.1 MG $ 2.177  
J7340** Carbidopa 5mg/Levodopa 20mg 5mg/20mg Invoice  
J7342** Ciprofloxacin (otic suspension) (OTIPRIO) 6 MG/1ML $ 30.019 Added 05/10/2018
J7345** Aminolevulinic Acid Hcl (Ameluz) 10 MG $ 1.431 Added January 2018
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.  
J9057** Copanlisib (Aliqopa) 1 MG $ 80.804 Added January 2019
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 Invoice No new pricing available for the 2018-2019 flu season.
Q2037 Fluvirin vacc, 3 yrs & >, im 0.5 ML Invoice No new pricing available for the 2018-2019 flu season.
Q2038 Fluzone vacc, 3 yrs & >, im 0.5 ML Invoice No new pricing available for the 2018-2019 flu season.
Q2039** Not Otherwise Classified flu vacc, 3 yrs & >, im 0.5 ML Invoice Effective 01/01/2018 forward use CPT code 90756 for Flucelvax. If drug has a assigned code you must use the correct code.
Q2040** tisagenlecleucel (Kymriah) Per infusion $503,500.000 Added January 2018
Q4105** Integra Omnigraft 1 SQ CM $ 54.082  
Q4110** PriMatrix and PriMatrix AG 1 SQ CM $ 33.668  
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  
Q4136** E-Z Derm 1 SQ CM Invoice added 04/05/18
Q4137** Amnioexcel or Biodexcel 1 SQ CM 83.952 Pricing added 10/23/2017
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  
Q4154** Biovance 1 SQ CM Invoice Added 05/2018
Q4158** Kerecis Omega3 Wound (Marigen) 1 SQ CM 38.230 Pricing added 11/02/17
Q4159** Affinity 1 SQ CM Invoice Added September 2018
Q4160** NuShield 1 SQ CM 212.000 Added 10/17
Q4161** Bio-connekt 1 SQ CM Invoice  
Q4162** Amnio bio, woundex flow 1 SQ CM Invoice  
Q4163** Amnio bio, woundex 1 SQ CM Invoice  
Q4164** Helicoll 1 SQ CM Invoice  
Q4165** Keramatrix 1 SQ CM Invoice  
Q4169** Artacent Wound 1 SQ CM Invoice Added 07/2018
Q4173** Palingen or Palingen Xplus 1 SQ CM Invoice Added 11/02/17
Q4174** Palingen or promatrx 1 SQ CM Invoice Added 05/2018
Q4175** MicroDerm 1 SQ CM Invoice Added 10/17
Q4176** Neopatch 1 SQ CM Invoice Added January 2018
Q4177** Floweramnioflo 0.1 CC Invoice Added January 2018
Q4178** Floweraminopatch 1 SQ CM Invoice Added January 2018
Q4179** Flowerderm 1 SQ CM Invoice Added January 2018
Q4180** Revita 1 SQ CM 123.667 Added January 2018
Q4181** Amino wound 1 SQ CM Invoice Added January 2018
Q4182** Transcyte 1 SQ CM Invoice Added January 2018
Q5108** Pegfilgrastim-jmdb (Fulphila) 0.5 MG 368.792 Added October 2018
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  
Q9985** Hydroxyprogesterone Caporate (other forms)   Invoice End dated 12/31/2017
Q9986** Hydroxyprogesterone Caporate (Makena) 10 MG $ 32.408 End dated 12/31/2017/ see new code J1726
Q9988** Platelets, Pathogen Reduced   invoice Added 10/17

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