Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective January 1, 2018 through March 31, 2018
Revised: 02.27.19
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.html![]()
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. |
| 90689 | VACC IIV4 NO PRSRV | Non FDA Approved | ||
| 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 | |
| A9513** | lutetium lu 177 dotatate (Lutathera) | 1 mci | 5035.00 | Updated dosage and pricing eff 01/01/2019 |
| A9587** | Gallium ga-68, dotatate, diagnostic, | Per 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 | 0.452 | |
| 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. | ||
| J0584** | Burosumab-twza (Crysvita) | 1 MG | $ 360.400 | Added January 2019 |
| J0620** | Calcium glycerophosphate/Calcium lactate | 10 ML | 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 | |
| J1746** | Ibalizumab-uiyk (Trogarzo) | 10 MG | $ 60.306 | Added January 2019 |
| J1726** | Hydroxyprogesterone Caproate (Makena) | 10 MG | $ 32.408 | Added January 2018 |
| 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. | ||
| 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 | |
| J2797** | Rolapitant (Varubi) | 0.5 MG | $ 10.152 | Added January 2019 |
| 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. | ||
| 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 | |
| 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 |
| J7320** | Hyaluronan or derivative (Genvisc 850) | 1 mg | $ 7.195 | Added October 2018 |
| 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 |
| 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 | |
| J9173** | Inj. Durvalumab (Imfinzi) | 10 MG | $ 74.304 | Added January 2019 |
| J9203** | Mylotarg (Gemtuzumab ozogamicin) | 0.1 MG | $ 193.155 | Added October 2018 |
| J9213** | Interferon alfa-2a inj | 3 MIL UNITS | Invoice | |
| J9215** | Interferon, alfa-n3 | 250,000 IU | $ 23.834 | |
| J9229** | Inotuzumab Ozogamicin (Besponsa) | 0.1 MG | $ 2,268.518 | Added January 2019 |
| 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 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4110** | PriMatrix and PriMatrix AG | 1 SQ CM | $ 33.668 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4118** | Matristem Micromatrix | 1 MG | $ 2.433 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4119** | Matristem Micromatrix | 1 SQ CM | $ 2.470 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4122** | Dermacell | 1 SQ CM | Invoice | |
| Q4124** | Oasis Ultra Tri-Layer Wound Matrix | 1 SQ CM | $ 11.400 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| 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 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| 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 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4152** | Dermapure | 1 SQ CM | 88.113 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4154** | Biovance | 1 SQ CM | Invoice | Added 05/2018 |
| Q4158** | Kerecis Omega3 Wound (Marigen) | 1 SQ CM | 38.230 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4159** | Affinity | 1 SQ CM | Invoice | Added September 2018 |
| Q4160** | NuShield | 1 SQ CM | 212.000 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| 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 | Effective 01/01/2019 - CGS has decided to base payment on invoice information. Skin substitutes/wound care products are not injectable drugs and therefore do not fall under the same guidelines for pricing injectable drugs. Invoice information will be required with claim submitted. |
| Q4181** | Amino wound | 1 SQ CM | Invoice | Added January 2018 |
| Q4182** | Transcyte | 1 SQ CM | Invoice | Added January 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 | |

