Skip to Main Content

Print | Bookmark | Font Size: + |

Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective October 1, 2019 through December 31, 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 4Q19 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: Skin substitutes/wound care base products are not injectable drugs and therefore, do not fall under the same guidelines for pricing. Invoice information will be required with claim submitted if not CMS priced.

Note 5: ** - 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
A9583** Gadofosveset trisodium inj (Ablavar) 1 ML Invoice Added November 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 (Axumin) 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
J0121** Inj., omadacycline, 1 mg (Nuzyra) 1 MG $ 3.657 Added October 2019
J0122** Inj., eravacycline, 1 mg (Xerava) 1 MG $ 1.039 Added October 2019
J0135** Adalimumab injection 20 MG (Humira) Considered self-administered. Added November 2019
J0200** Alatrofloxacin mesylate (Trovan IV) 100 MG Invoice  
J0205** Alglucerase injection (Ceredase) 10 UNITS Invoice Added November 2019
J0215** Alefacept (Amevive) 0.5 MG Invoice Added November 2019
J0222** Inj., patisiran, 0.1 mg (Onpattro) 0.1 MG $ 100.700 Added October 2019
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
J0288** Ampho b cholesteryl sulfate (Amphotec) 10 MG Invoice Added November 2019
J0291** Inj., plazomicin, 5 mg (Zemdri) 5 MG $ 3.339 Added October 2019
J0364** Apomorphine Hydrochloride (Apokyn) Considered self-administered. Added November 2019
J0365** Aprotinin (Trasylol) 10000 KIU Invoice Added November 2019
J0380** metaraminol bitartrate, inj (Aramine) 10 MG Invoice  
J0390** Chloroquine injection (Aralen Hcl) 250 MG Invoice  
J0395** Arbutamine HCl injection (Genesa) 1 MG Invoice  
J0400** Aripiprazole injection (Abilify) 0.25 MG Invoice Added November 2019
J0520** Bethanechol chloride inject Oral drug considered part of procedure in physician's office.  
J0574** Buprenorphine/Naloxone Considered self-administered. Added November 2019
J0593** Inj., lanadelumab-flyo, 1 mg (Takhzyro) 1 MG $ 77.981 Added October 2019
J0620** Calcium glycerophosphate/Calcium lactate (Calphosan) 10 ML Invoice  
J0630** Calcitonin salmon injection (Miacalcin) Considered self-administered. Added November 2019
J0715** Ceftizoxime sodium / 500 MG (Cefizox) 500 MG Invoice  
J0890** Peginesatide injection (Omontys) 0.1 MG Invoice Added November 2019
J0945** Brompheniramine Maleate 10 MG Invoice Added November 2019
J1094** Dexamethasone Acetate 1 MG Invoice Added November 2019
J1096** Dexametha opth insert 0.1 mg (Dextenza) 0.1 MG $ 142.790 Added October 2019
J1097** Phenylep ketorolac opth soln (Omidria) 1 ML $ 123.225 Added October 2019
J1130** Diclofenac sodium 0.5 MG Invoice Added 05/2017 / Updated August 2019
J1260** Dolasetron mesylate (Anzemat) 10 MG $ 6.214 Added November 2019
J1267** Doripenem injection 10 MG $ 0.764 Added November 2019
J1324** Enfuvirtide Considered self-administered.  
J1327** Eptifibatide injection (Integrilin) 5 MG $ 24.907 Added November 2019
J1330** Ergonovine maleate, injection 1 GM Invoice Added August 2019
J1438** Etanercept injection (Enbrel) Considered self-administered. Added November 2019
J1443** Ferric Pyrophosphate Citrate Sol (Triferic) 0.1 MG Invoice  
J1444** Inj, ferric pyrophosphate citrate powder, 0.1 mg of iron 0.1 MG Invoice Added July 2019
J1451** Fomepizole, 15 mg 15 MG $ 11.357 Added November 2019
J1455** Foscarnet sodium injection (Foscavir) 1000 MG $ 82.268 Added November 2019
J1457** Gallium nitrate injection (Ganite) 1 MG Invoice Added November 2019
J1573** Hepagam b intravenous, inj 0.5 ML $ 60.057 Added November 2019
J1590** Gatifloxacin injection Considered self-administered. End Date 12/31/2016
J1595** Injection glatiramer acetate Considered self-administered.  
J1600** Gold sodium thiomaleate inj 50 MG Invoice Added November 2019
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
J1790** Droperidol injection 5 MG $ 4.887 Added November 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
J1840** Kanamycin sulfate 500 MG inj (Kantrex) 500 MG Invoice Added November 2019
J1850** Kanamycin sulfate 75 MG inj (Kantrex) 75 MG Invoice Added November 2019
J1890** Cephalothin sodium injection 1 G Invoice  
J1945** Lepirudin (Refludan) 50 MG Invoice Added November 2019
J1960** Levorphanol tartrate 2 MG Invoice Updated August 2019
J1990** Chlordiazepoxide injection 100 MG Invoice  
J2170** Mecasermin Considered self-administered.  
J2180** Meperidine and Promethazine hcl 50 MG Invoice Added November 2019
J2265** Minocycline Hydrochloride Considered self-administered.  
J2278KD** Ziconotide injection 1 MCG Invoice  
J2320** Nandrolone decanoate 50 MG 50 MG Invoice Updated August 2019
J2325** Nesiritide injection (Natrecor) 0.1 MG Invoice Added December 2019
J2354** Octreotide Acetate inj, non-depot (Sandostatin) Considered self-administered. Added December 2019
J2355** Oprelvekin injection (Neumega) 5 MG Invoice Added December 2019
J2370** Phenylephrine hcl injection (Biorphen/Vazculep) 1 ML $2.120 Eff. Date 11/1/2019 - Added December 2019
J2410** Oxymorphone hcl injection (Numorphan hcl/Opana) 1 MG Invoice  Added December 2019
J2440** Papaverin hcl injection 60 MG $36.400 Added December 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  
J2590** Oxytocin injection (Pitocin) 10 UNITS $0.859 Added December 2019
J2650** Prednisolone acetate (Cotolone/Key-Pred) 1 ML Invoice  Updated August 2019
J2670** Tolazoline hcl injection 25 MG  Invoice   
J2730** Pralidoxime chloride inj (Protopam Chloride) 1 GM $91.902 Added December 2019
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
J2850** Inj secretin synthetic human (Chirhostim) 1 MCG $27.494 Added December 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.  
J3031** Inj. Fremanezumab-vfrm (Ajovy) 1 MG $ 2.709 Added October 2019
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
J7314** Inj, yutiq 0.01 MG $ 491.333 Added October 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
J7326** Hyaluronate sodium (Gel-One) per dose-30 MG/3 ML $ 1,166.000 Added January 2019/updated June 2019
J7328** Hyaluronan or derivative, gel-syn (Gelsyn-3) 0.1 MG $ 2.177  
J7331** Synojoynt, inj. 1 MG Invoice Added October 2019
J7332** Inj., triluron, 1 mg 1 MG $ 25.917 Added October 2019
J7342** Ciprofloxacin (otic suspension) (OTIPRIO) 6 MG/1ML $ 30.019 Added 05/10/2018
J7401** Mometasone furoate sinus imp (Sinuva Sinus Implant) 10 MCG $ 10.011 Added October 2019
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
J9118** Inj. Calaspargase pegol-mknl 10 UNITS Invoice Added October 2019
J9165** Diethylstilbestrol diphosphate injection 250 MG Invoice  
J9210** Inj., emapalumab-lzsg, 1 mg (Gamifant) 1 MG $ 786.732 Added October 2019
J9213** Interferon alfa-2a inj 3 MIL UNITS Invoice  
J9215** Interferon, alfa-n3 (Alferon-N) 250,000 IU $ 31.800 Updated August 2019
J9269** Inj. Tagraxofusp-erzs 10 mcg (Elzonris) 10 MCG $ 270.611 Added October 2019
J9270** Plicamycin (mithramycin) inj 2.5 MG Invoice  
J9313** Inj., lumoxiti, 0.01 mg 0.01 MG $ 22.083 Added October 2019
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 and 90674 for Flucelvax-no preservatives
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 See Note: 4
Q4114** Integra flowable wound matri 1 CC Invoice Added May 2019 / See Note: 4
Q4116** Alloderm skin sub 1 SQ CM Invoice Added May 2019 / See Note: 4
Q4117** Hyalomatrix 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4118** Matristem Micromatrix 1 MG Invoice See Note: 4
Q4119** Matristem Micromatrix 1 SQ CM Invoice See Note: 4
Q4122** Dermacell, awm porous sq cm 1 SQ CM Invoice See Note: 4
Q4123** Alloskin RT 1 SQ CM Invoice Added May 2019
Q4124** Oasis Ultra Tri-Layer Wound Matrix 1 SQ CM Invoice See Note: 4
Q4125** Arthroflex 1 SQ CM Invoice See Note: 4
Q4126** Memoderm 1 SQ CM Invoice See Note: 4
Q4127** Talymed 1 SQ CM Invoice See Note: 4
Q4128** Flex HD or Allopatch HD 1 SQ CM Invoice See Note: 4
Q4129** Unite Biomatrix 1 SQ CM Invoice End Date 12/31/2016
Q4130** Strattice TM 1 SQ CM Invoice See Note: 4
Q4136** E-Z Derm 1 SQ CM Invoice Added 04/05/2018
Q4138** Biodfence dryflex 1 SQ CM Invoice See Note: 4
Q4139* Amniomatrix or Biodmatrix 1 CC Invoice See Note: 4
Q4140** Biodfence 1 SQ CM Invoice See Note: 4
Q4141** Alloskin ac 1 SQ CM Invoice See Note: 4
Q4142** Xcm Biologic Tissue Matrix 1 SQ CM Invoice See Note: 4
Q4143** Repriza 1 SQ CM Invoice See Note: 4
Q4146** Tensix 1 SQ CM Invoice See Note: 4
Q4147** Architect Extracellular Matrix 1 SQ CM Invoice See Note: 4
Q4148** Neox 1k 1 SQ CM Invoice See Note: 4
Q4149** Excellagen 0.1 CC Invoice See Note: 4
Q4152** Dermapure 1 SQ CM Invoice See Note: 4
Q4158** Kerecis Omega3 Wound (Marigen) 1 SQ CM Invoice See Note: 4
Q4161** Bio-connekt 1 SQ CM Invoice See Note: 4
Q4162** Amnio bio, woundex flow 1 SQ CM Invoice See Note: 4
Q4163** Amnio bio, woundex 1 SQ CM Invoice See Note: 4
Q4164** Helicoll 1 SQ CM Invoice See Note: 4
Q4165** Keramatrix 1 SQ CM Invoice See Note: 4
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 See Note: 4
Q4181** Amino wound 1 SQ CM Invoice Added January 2018
Q4182** Transcyte 1 SQ CM Invoice Added January 2018
Q4184** Cellesta or duo per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4187** Epicord 1 SQ CM Invoice Added April 2019
Q4205** Membrane graft or wrap sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4206** Fluid flow or fluid gf 1 cc 1 CC Invoice Added October 2019 / See Note: 4
Q4208** Novafix per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4209** Surgraft per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4210** Axolotl graf dualgraf sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4211** Amnion bio or axobio sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4212** Allogen, per cc 1 CC Invoice Added October 2019 / See Note: 4
Q4213** Ascent, 0.5 mg 0.5 MG $44.167 Updated December 2019
Q4214** Cellesta cord per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4215** Axolotl ambient, cryo 0.1 mg 0.1 MG Invoice Added October 2019 / See Note: 4
Q4216** Artacent cord per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4217** Woundfix biowound plus xplus 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4218** Surgicord per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4219** Surgigraft dual per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4220** Bellacell HD, Surederm sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4221** Amniowrap2 per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4222** Progenamatrix, per sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4226** Myown harv prep proc sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
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 (Truxima) 10 MG $ 89.628 Added July 2019 - Invoice
Price Eff. 11/09/2019
Q5116** Inj., trazimera, 10 mg 10 MG Invoice Added October 2019
Q5118** Inj., zirabev, 10 mg 10 MG Invoice Added October 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

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved