Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective April 1, 2019 through June 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.html![]()
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 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 | $ 259.170 | Updated dosage and pricing eff 01/01/2019 Updated price 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 | $ 142.559 | 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. | ||
| 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 | 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. | ||
| J1443** | Ferric Pyrophosphate Citrate Sol (Triferic) | 0.1mg | Invoice | |
| 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 | |
| J1746** | Ibalizumab-uiyk (Trogarzo) | 10 MG | $ 60.306 | Added January 2019 |
| J1726** | Hydroxyprogesterone Caproate (Makena) | 10 MG | $ 28.940 | Added January 2018 / Updated August 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 | |
| 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 | |
| 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 | $ 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 07/2017 / Eff. 6/29/2019-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 |
| J9262** | Omacetaxine Mepesuccinate(Synribo) | 0.01 MG | $ 2.529 | |
| J9270** | Plicamycin (mithramycin) inj | 2.5 MG | Invoice | |
| J9600** | Porfimer Sodium injection (Photofrin) | 75 MG | $ 22,302.400 | Eff. 6/10/2019-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 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/ 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. |
| Q4110** | PriMatrix and PriMatrix AG | 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 04/05/18 |
| Q4137** | Amnioexcel or Biodexcel | 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. |
| 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 | 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. |
| Q4154** | Biovance | 1 SQ CM | Invoice | Added 05/2018 |
| 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. |
| Q4160** | NuShield | 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 |
| 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 | |

