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Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective July 1, 2019 through September 30, 2019

Revised: 12.09.19

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 3Q18 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 2019-2020 flu season.
90654 Flu vaccine, intradermal, no preserv Non FDA Approved No new pricing available for the 2019-2020 flu season.
90655 Flu vaccine no preserv 6-35m, im 0.25 ML Invoice No new pricing available for the 2019-2020 flu season.
90657 Flu vaccine, 6-35 mo, im 0.25 ML Invoice No new pricing available for the 2019-2020 flu season.
90661 Flu vaccine, derived from cell cultures, subunit 45 mcg/0.5 ML Invoice No new pricing available for the 2019-2020 flu season.
90673 Flublok, trivalent 18 & > 0.5 ml Invoice No new pricing available for the 2019-2020 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 $ 259.170 Updated dosage and pricing eff 01/01/2019 Updated pricing Eff June 2019/ Updated price July 2019
A9587** Gallium ga-68, dotatate, diagnostic, (Netspot) 0.1 Mci. $ 68.704 Updated pricing 10/2017 / Updated August 2019
A9588** Fluciclovine f-18, diagnostic Per Mci Invoice Changed pricing to invoice
A9606** Radium Ra 223 dichloride (Xofigo) MicroCurie $ 145.198 Eff:1/1/2015 / Pricing change EFF 10/01/17 / price change 7/2018 / Updated August 2019
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.  
J0620** Calcium glycerophosphate/Calcium lactate 10 ML Invoice  
J0715** Ceftizoxime sodium / 500 MG 500 MG Invoice  
J1130** Diclofenac sodium 0.5 mg Invoice Added 05/2017 / Updated August 2019
J1301** Edaravone (Radicava) 1 MG $ 19.570 Added January 2019
J1324** Enfuvirtide Considered self-administered.  
J1330** Ergonovine maleate, injection 1 gm Invoice Added August 2019
J1443** Ferric Pyrophosphate Citrate Sol (Triferic) 0.1mg Invoice  
J1444** Inj, ferric pyrophosphate citrate powder, 0.1 mg of iron 0.1 mg Invoice Added July 2019
J1590** Gatifloxacin injection Considered self-administered. End Date 12/31/2016
J1595** Injection glatiramer acetate Considered self-administered.  
J1628** Guselkumab (Tremfya) 1 ML $ 11,511.028 Added October 2019
J1675** Histrelin Acetate Considered self-administered.  
J1680** fibrinogen concentrate human 100 MG $ 103.550 End Date 12/31/2012
J1700** Hydrocortisone acetate inj 25 MG Invoice Updated August 2019
J1710** Hydrocortisone sodium ph inj 50 MG Invoice  
J1726** Hydroxyprogesterone Caproate (Makena) 10 MG $ 28.940 Added January 2018 / Updated August 2019
J1746** Ibalizumab-uiyk (Trogarzo) 10 MG $ 60.306 Added January 2019
J1826** Interferon beta-1a / 30 mcg (Avonex) Considered self-administered. Updated August 2019
J1830** Interferon beta-1b / .25 MG Not covered by carrier.  
J1833** Isavuconazonium Sulfate (Cresemba) 1 MG $ 0.899 Updated August 2019
J1890** Cephalothin sodium injection 1 G Invoice  
J1960** Levorphanol tartrate 2 MG Invoice Updated August 2019
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 Invoice Updated August 2019
J2502** Pasireotide (Signifor LAR) 1 MG $ 223.979 Updated August 2019
J2513** Pentastarch 10% solution 10% Invoice  
J2547** Peramivir (Rapivab) 1 MG $ 1.678  
J2650** Prednisolone acetate 1 ML Invoice Updated August 2019
J2670** Tolazoline hcl injection 25 MG Invoice  
J2797** Rolapitant (Varubi) 0.5 MG $ 0.939 Added January 2019 / Updated August 2019
J2840** Seblipase alfa (Kanuma) 1 MG $ 541.130 Added January 2017 / Updated August 2019
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.  
J3265** Injection torsemide 10 mg/ml 10 MG Invoice Updated August 2019
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  
J7191** Factor viii (porcine) 1 IU Invoice  
J7296** Levonorgestrel releasing intrauterine contraceptive system, (Kyleena) 19.5 MG $ 1,010.721 Added January 2018 / Updated August 2019
J7315** Mitomycin - ophthalmic 0.2 mg topical solution Considered part of procedure Added September 2018
J7318** Hyaluronic acid (Durolane) 1 mg. $ 17.225 Added January 2019/updated June 2019
J7320** Hyaluronate sodium or derivative (Genvisc 850) 1 mg $ 16.918 Added October 2018/Updated pricing 04/15/2019
J7322** Hyaluronic acid (Hymovis) 1 MG $ 31.668 Added January 2017/ Updated July 2017 /
Updated August 2019
J7324** Orthovisc inj per dose per dose/2 ml. $ 506.680 CMS stopped pricing/Updated price May 2019
J7326** Hyaluronate sodium (Gel-One) per dose-30mg/3ml $ 1,166.000 Added January 2019/updated June 2019
J7327** Monovisc inj per dose per dose/4 ml. $ 1,511.147 CMS stopped pricing/Updated price May 2019
J7328** Hyaluronan or derivative, gel-syn (Gelsyn-3) 0.1 MG $ 2.177  
J7342** Ciprofloxacin (otic suspension) (OTIPRIO) 6 MG/1ML $ 30.019 Added 05/10/2018
J7604 - J7699** Inhalation Solutions Considered part of procedure in physician's office. Updated March 2019
J8561** Everolimus, 0.25 MG Should be billed to DMAC. End Date 12/31/2012
J9057** Copanlisib (Aliqopa) 1 MG $ 82.420 Added January 2019 / Updated August 2019
J9165** Diethylstilbestrol diphosphate injection 250 MG Invoice  
J9203** Gemtuzumab ozogamicin (Mylotarg) 0.1 MG $ 198.950 Added October 2018 / Updated August 2019
J9213** Interferon alfa-2a inj 3 MIL UNITS Invoice  
J9215** Interferon, alfa-n3 (Alferon-N) 250,000 IU $ 31.800 Updated August 2019
J9229** Inotuzumab Ozogamicin (Besponsa) 0.1 MG $ 2,268.518 Added January 2019
J9270** Plicamycin (mithramycin) inj 2.5 MG Invoice  
J9600** Porfimer Sodium injection (Photofrin) 75 MG $ 22,302.400 Updated August 2019
Q0174** Thiethylperazine maleate, 10mg Should be billed to DMAC.  
Q0179** Ondansetron hcl 9 mg oral Should be billed to DMAC. End Date 12/31/2011
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 2019-2020 flu season.
Q2037 Fluvirin vacc, 3 yrs & >, im 0.5 ML Invoice No new pricing available for the 2019-2020 flu season.
Q2038 Fluzone vacc, 3 yrs & >, im 0.5 ML Invoice No new pricing available for the 2019-2020 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 / End Date 12/31/2018
Q4103** Oasis Burn Matrix 1 SQ CM Invoice Added May 2019
Q4105** Integra Omnigraft 1 SQ CM Invoice 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.
Q4114** Integra flowable wound matri 1 CC Invoice Added May 2019
Q4116** Alloderm skin sub 1 SQ CM Invoice Added May 2019
Q4118** Matristem Micromatrix 1 MG Invoice 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 Invoice 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.
End Date 12/31/2016
Q4122** Dermacell 1 SQ CM Invoice  
Q4123** Alloskin RT 1 SQ CM Invoice Added May 2019
Q4124** Oasis Ultra Tri-Layer Wound Matrix 1 SQ CM Invoice 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 End Date 12/31/2016
Q4130** Strattice TM 1 SQ CM Invoice  
Q4136** E-Z Derm 1 SQ CM Invoice Added 04/05/2018
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  
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 Invoice 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 Invoice 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.
Q4158** Kerecis Omega3 Wound (Marigen) 1 SQ CM Invoice 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
Q4172** PuraPly 1 SQ CM Invoice Added May 2019 / End Date 12/31/2018
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 Invoice 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
Q4187** Epicord 1 SQ CM Invoice Added April 2019
Q4213** Ascent, 0.5 mg 0.5 MG $44.167 Added December 2019
Q5107** Inj, bevacizumab-awwb, biosimilar (Mvasi) 10 MG $ 71.804 Eff. 07/18/2019 - Added August 2019
Q5112** Inj, ontruzant 10mg 10 MG Invoice Added July 2019
Q5113** Inj, herzuma 10mg 10 MG Invoice Added July 2019
Q5114** Inj, ogivri 10mg 10 MG Invoice Added July 2019
Q5115** Inj, rituximab-abbs, bio 10mg 10 MG Invoice Added July 2019
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 End Date 12/31/2016
Q9985** Hydroxyprogesterone Caporate (other forms)   Invoice End Date 12/31/2017
Q9986** Hydroxyprogesterone Caporate (Makena) 10 MG $ 32.408 End date 12/31/2017/ see new code J1726
Q9988** Platelets, Pathogen Reduced   invoice Added 10/17 / End Date 12/31/2017

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