Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective January 1, 2020 through March 31, 2020
Revised 06.17.20
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 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 | |
| A9500** | Tc99m sestamibi | per study dose | Invoice | Added February 2020 |
| A9502** | Tc99m tetrofosmin | per study dose | Invoice | Added February 2020 |
| 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 |
| J0120** | Tetracycline | Invoice | Added January 2020 | |
| 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 |
| J0210** | Methyldopate hcl injection | 250 MG | $ 42.400 | Added January 2020 |
| J0215** | Alefacept (Amevive) | 0.5 MG | Invoice | Added November 2019 |
| J0270** | Alprostadil, 1.25 MCG (Caverjet, Edex) | 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 January 2020 | |
| 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. | ||
| J0573** | Buprenorphine/naloxone (Suboxone) | Considered part of procedure. | Added March 2020 | |
| J0574** | Buprenorphine/Naloxone | Considered self-administered. | Added November 2019 | |
| J0593** | Inj., lanadelumab-flyo, 1 mg (Takhzyro) | Considered self-administered. | Added October 2019 / Updated January 2020 | |
| J0599** | Injection, C-1 esterase inhibitor (human) (Haegarda) | Considered self-administered. | Added January 2020 | |
| J0620** | Calcium glycerophosphate/Calcium lactate (Calphosan) | 10 ML | Invoice | |
| J0630** | Calcitonin salmon injection (Miacalcin) | Considered self-administered. | Added November 2019 | |
| J0706** | Caffeine citrate injection (Cafcit) | 5 MG | $ 1.855 | Added January 2020 |
| J0715** | Ceftizoxime sodium / 500 MG (Cefizox) | 500 MG | Invoice | |
| J0745** | Inj codeine phosphate / 30 MG | 30 MG | Invoice | Added January 2020 |
| J0800** | Corticotropin injection (Acthar) | Considered self-administered. | Added January 2020 | |
| 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 (Fuzeon) | 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 |
| J1559** | Hizentra injection | Considered self-administered. | Added January 2020 | |
| J1562** | Injection, Immune Globulin (Vivaglobin) | Considered self-administered. | Added January 2020 | |
| 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 (Copaxone, Glatopa) | 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 (Supprelin) | 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 |
| J1741** | Ibuprofen injection | Considered self-administered. | Added January 2020 | |
| J1744** | Injection, Icatibant, 1 mg (Firazyr) | Considered self-administered. | Added January 2020 | |
| J1790** | Droperidol injection | 5 MG | $ 4.887 | Added November 2019 |
| J1815** | Insulin injection | Considered self-administered. | Added January 2020 | |
| J1817** | Insulin for insulin pump use | Considered self-administered. | Added January 2020 | |
| J1826** | Interferon beta-1a / 30 mcg (Avonex) | Considered self-administered. | Updated August 2019 | |
| J1830** | Interferon beta-1b / .25 MG (Betaseron, Extavia) | Considered self-administered. | ||
| 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 (Increlex) | Considered self-administered. | ||
| J2180** | Meperidine and Promethazine hcl | 50 MG | Invoice | Added November 2019 |
| J2212** | Injection, Methylnaltrexone, 0.1 mg (Relistor) | Considered self-administered. | Added January 2020 | |
| J2265** | Minocycline Hydrochloride (Minocin) | 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 | Considered self-administered. | Added December 2019 / Updated January 2020 | |
| J2502** | Pasireotide (Signifor LAR) | 1 MG | $ 223.979 | Updated August 2019 |
| J2513** | Pentastarch 10% solution (Pentaspan) | 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 |
| J2810** | Inj theophylline per 40 MG | 40 MG | Invoice | Added January 2020 |
| 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 | |
| J2993** | Reteplase injection (Retavase) | 18.1 MG | Invoice | Added January 2020 |
| J3030** | Sumatriptan Succinate (Imitrex) | Considered self-administered. | ||
| J3031** | Inj. Fremanezumab-vfrm (Ajovy) | Considered self-administered. | Added October 2019 / Updated January 2020 | |
| J3070** | Pentazocine injection | 30 MG | Invoice | Added January 2020 |
| J3110** | Teriparatide injection (Forteo) | Considered self-administered. | ||
| J3246** | Tirofiban Hcl (Aggrastat) | 0.25 MG | $ 10.978 | Added January 2020 |
| J3265** | Injection torsemide 10 mg/ml (Demadex) | 10 MG | Invoice | Updated August 2019 |
| J3280** | Thiethylperazine maleate, inj (Norzine, Torecan) | 10 MG | Invoice | |
| J3303** | Triamcinolone hexacetonl inj (Aristospan) | 5 MG | Invoice | Added January 2020 |
| J3310** | Perphenazine (Trilafon) | 5 MG | Invoice | Updated January 2020 |
| J3355** | Urofollitropin, 75 iu (Bravelle) | Considered self-administered. | Added January 2020 | |
| J3365** | Urokinase 250,000 IU inj (Abbokinase) | 250000 IU | Invoice | Added January 2020 |
| J3470** | Hyaluronidase injection (Amphadase) | 150 UNITS | $ 59.148 | Added January 2020 |
| J7100** | Dextran 40 infusion (LMD in dextrose) | 500 ML | $ 28.122 | Added January 2020 |
| J7110** | Dextran 75 infusion | 500 ML | Invoice | Added January 2020 |
| J7121** | 5% Dextrose in lactated ringers | 1000 CC | Invoice | |
| J7130** | Hypertonic saline solution | 20 CC | Invoice | |
| J7131** | Hypertonic saline solution | 1 ML | Invoice | Added January 2020 |
| J7191** | Factor viii (porcine) (Hyate:C) | 1 IU | Invoice | |
| J7296** | Levonorgestrel releasing intrauterine contraceptive system, (Kyleena) | 19.5 MG | $ 1,010.721 | Added January 2018 / Updated August 2019 |
| J7309** | Methyl Aminolevulinate, top (Metvixia) | 1 GM | Invoice | Added January 2020 |
| J7310** | Ganciclovir long act implant (Vitrasert) | 4.5 MG | Invoice | Added January 2020 |
| 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 | |
| J7330** | Cultured chondrocytes implnt (Maci) | 1 EA | Invoice | Added January 2020 |
| 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 | $ 10.461 | Added October 2019 / Updated January 2020 |
| J7500** | Azathioprine oral 50 mg (Azasan) | Should be billed to DMAC. | Added January 2020 | |
| J7501** | Azathioprine parenteral | 100 MG | $ 265.000 | Added January 2020 |
| J7502** | Cyclosporine oral 100 mg | Should be billed to DMAC. | Added January 2020 | |
| J7503** | Tacrol envarsus (Envarsus XR) | Considered self-administered. | Added January 2020 | |
| J7505** | Monoclonal anitibodies | 5 MG | Invoice | Added January 2020 |
| J7507** | Tacrolimus oral per 1 mg (Prograf) | Should be billed to DMAC. | Added January 2020 | |
| J7508** | Tacrolimus Ex Rel oral 0.1 mg (Astagraf XL) | Should be billed to DMAC. | Added January 2020 | |
| J7509** | Methylprednisolone oral | Should be billed to DMAC. | Added January 2020 | |
| J7510** | Prednisolone oral per 5 mg | Should be billed to DMAC. | Added January 2020 | |
| J7512** | Prednisone ir or dr oral 1 mg | Considered self-administered. | Added January 2020 | |
| J7513** | Daclizumab, parenteral (Zenapax, Zinbryta) | 25 MG | Invoice | Added January 2020 |
| J7515** | Cyclosporine oral 25 mg | Should be billed to DMAC. | Added January 2020 | |
| J7517** | Mycophenolate mofetil oral (Cellcept) | Should be billed to DMAC. | Added January 2020 | |
| J7518** | Mycophenolic acid (Myfortic) | Should be billed to DMAC. | Added January 2020 | |
| J7520** | Sirolimus, oral (Rapamune) | Should be billed to DMAC. | Added January 2020 | |
| J7527** | Oral Everolimus (Afinitor, Zortress) | Should be billed to DMAC. | Added January 2020 | |
| J7604 - J7699** | Inhalation Solutions | Considered part of procedure in physician's office. | Updated March 2019 | |
| J8499** | Estramustine Phosphate Sodium (Emcyt) | Should be billed to DMAC. | Added January 2020 | |
| J8501** | Oral aprepitant (Emend) | Should be billed to DMAC. | Added January 2020 | |
| J8510** | Oral busulfan (Myleran) | Should be billed to DMAC. | Added January 2020 | |
| J8520** | Capecitabine, oral, 150 mg (Xeloda) | Should be billed to DMAC. | Added January 2020 | |
| J8521** | Capecitabine, oral, 500 mg (Xeloda) | Should be billed to DMAC. | Added January 2020 | |
| J8530** | Cyclophosphamide oral 25 mg | Should be billed to DMAC. | Added January 2020 | |
| J8540** | Oral dexamethasone (Hidex, Taperdex) | Should be billed to DMAC. | Added January 2020 | |
| J8560** | Etoposide oral 50 mg | Should be billed to DMAC. | Added January 2020 | |
| J8561** | Everolimus, 0.25 MG | Should be billed to DMAC. | End Date 12/31/2012 | |
| J8562** | Oral fludarabine phosphate (Oforta) | Should be billed to DMAC. | Added January 2020 | |
| J8600** | Melphalan oral 2 mg (Alkeran) | Should be billed to DMAC. | Added January 2020 | |
| J8610** | Methotrexate oral 2.5 mg (Xatmep, Trexall) | Should be billed to DMAC. | Added January 2020 | |
| J8655** | Netupitant Palonosetron oral (Akynzeo) | Should be billed to DMAC. | Added January 2020 | |
| J8700** | Temozolomide (Temodar) | Should be billed to DMAC. | Added January 2020 | |
| J8705** | Topotecan oral (Hycamtin) | Should be billed to DMAC. | Added January 2020 | |
| J9015** | Aldesleukin injection (Proleukin) | 1 EA | $ 4,964.616 | Added January 2020 |
| J9020** | Asparaginase injection (Elspar) | 10000 UNITS | Invoice | Added January 2020 |
| J9057** | Copanlisib (Aliqopa) | 1 MG | $ 82.420 | Added January 2019 / Updated August 2019 |
| J9098** | Cytarabine liposome inj (Depocyt) | 10 MG | Invoice | Added January 2020 |
| J9118** | Inj. Calaspargase pegol-mknl (Asparlas) | 10 UNITS | $ 67.840 | Added October 2019 / Updated January 2020 |
| J9151** | Daunorubicin citrate inj (Daunoxome) | 10 MG | Invoice | Added January 2020 |
| J9160** | Denileukin diftitox inj (Ontak) | 300 MCG | Invoice | Added January 2020 |
| J9165** | Diethylstilbestrol diphosphate injection (Stilphostrol) | 250 MG | Invoice | |
| J9175** | Elliotts b solution per ml | 1 ML | $ 8.373 | Added January 2020 |
| J9199** | Gemcitabine Hydrochloride (Infugem) | 200 MG | $80.560 | Added March 2020 |
| J9210** | Inj., emapalumab-lzsg, 1 mg (Gamifant) | 1 MG | $ 357.963 | Added October 2019 / Updated January 2020 |
| J9212** | Inj., interferon alfacon-1, recomb, 1 mcg (Pegasys) | Considered self-administered. | Added January 2020 | |
| J9213** | Interferon alfa-2a inj (Roferon-A) | Considered self-administered. | Updated January 2020 | |
| J9215** | Interferon, alfa-n3 (Alferon-N) | 250,000 IU | $ 31.800 | Updated August 2019 |
| J9216** | Injection, interferon, gamma 1-B, 3 million units (Actimmune) | Considered self-administered. | Added January 2020 | |
| J9218** | Leuprolide acetate injection (Lupron) | Considered self-administered. | Added January 2020 | |
| J9219** | Leuprolide acetate implant | 65 MG | Invoice | Added January 2020 |
| J9230** | Mechlorethamine hcl inj (Mustargen) | 10 MG | Invoice | Added January 2020 |
| J9269** | Inj. Tagraxofusp-erzs 10 mcg (Elzonris) | 10 MCG | $ 270.611 | Added October 2019 |
| J9270** | Plicamycin inj (Mithracin) | 2.5 MG | Invoice | |
| J9313** | Inj., lumoxiti, 0.01 mg | 0.01 MG | $ 22.415 | Added October 2019 / Updated January 2020 |
| J9600** | Porfimer Sodium injection (Photofrin) | 75 MG | $ 22,302.400 | Updated August 2019 |
| P9043** | Plasma protein fract, 5%, 50 ml (Plasmanate 50 ml) | 50 ML | $ 23.871 | Added January 2020 |
| P9048** | Plasma protein fract, 5%, 250 ml (Plasmanate 250 ml) | 250 ML | $ 56.063 | Added January 2020 |
| Q0163** | Diphenhydramine HCl 50mg (Alercap, Banophen, Benadryl) | Should be billed to DMAC. | Added January 2020 | |
| Q0164** | Prochlorperazine maleate 5mg | Should be billed to DMAC. | Added January 2020 | |
| Q0166** | Granisetron hcl 1 mg oral | Should be billed to DMAC. | Added January 2020 | |
| Q0167** | Dronabinol 2.5mg oral (Marinol) | Should be billed to DMAC. | Added January 2020 | |
| Q0169** | Promethazine HCl 12.5mg oral | Should be billed to DMAC. | Added January 2020 | |
| Q0174** | Thiethylperazine maleate, 10mg | Should be billed to DMAC. | ||
| Q0179** | Ondansetron hcl 8 mg oral | Should be billed to DMAC. | End Date 12/31/2011 | |
| Q0180** | Dolasetron mesylate oral (Anzemet) | Should be billed to DMAC. | Added January 2020 | |
| Q0181** | Unspecified oral dosage form, FDA approved presription anti-emetic | Should be billed to DMAC. | ||
| Q0515** | Sermorelin acetate injection | 1 MCG | Invoice | Added January 2020 |
| Q2009** | Fosphenytoin inj PE (Cerebyx) | 50 MG | $ 5.062 | Added January 2020 |
| Q2017** | Teniposide, 50 mg | 50 MG | $ 2,645.707 | Added January 2020 |
| Q2026** | Radiesse injection | 0.1 ML | Invoice | |
| Q2028** | Sculptra | 0.5 MG | Invoice | |
| Q2033** | Flublok (quadravalent form) | 0.5 ML | Invoice | Added January 2020 |
| Q2034** | Agriflu | 0.05 ML | Invoice | |
| Q2035** | Afluria vacc, 3 yrs & >, im | 0.5 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| 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 |
| Q2047** | Peginesatide injection (Omontys) | 0.1 MG | Invoice | End Date 12/31/2012 |
| Q2049** | Imported Lipodox injection | 10 MG | $ 508.429 | Added January 2020 |
| Q4074** | Iloprost non-comp unit dose (Ventavis) | Considered part of procedure in physician's office. | Added January 2020 | |
| Q4100** | Skin substitutes; not otherwise specified | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
| Q4103** | Oasis Burn Matrix | 1 SQ CM | Invoice | Added May 2019 |
| Q4104** | Integra BMWD skin sub | 1 SQ CM | Invoice | Added January 2020 / See Note: 4 |
| Q4105** | Integra Omnigraft | 1 SQ CM | Invoice | See Note: 4 |
| Q4107** | Graftjacket skin sub | 1 SQ CM | Invoice | Added January 2020 / See Note: 4 |
| Q4108** | Integra matrix skin sub | 1 SQ CM | Invoice | Added January 2020 / See Note: 4 |
| Q4112** | Cymetra allograft | 1 CC | Invoice | Added January 2020 / See Note: 4 |
| Q4113** | Graftjacket express allograf | 1 CC | Invoice | Added January 2020 / 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 | End Date 12/31/2016 |
| 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 |
| Q4131** | Epifix | 1 SQ CM | Invoice | End Date 12/31/2018 |
| 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 |
| Q4166** | Cytal Wound/Burn Matrix | 1 SQ CM | Invoice | Added January 2020/See Note: 4 |
| Q4169** | Artacent Wound | 1 SQ CM | Invoice | Added 07/2018 |
| Q4172** | PuraPly | 1 SQ CM | Invoice | 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 |
| Q4197** | Puraply XT | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
| Q4205** | Membrane graft or wrap sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4206** | Fluid flow or fluid gf | 0.5 ML | $1,060.000 | Added October 2019 / Updated June 2020 |
| 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 |
| Q4231** | Corplex P | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
| Q4232** | Corplex | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
| Q5112** | Inj, ontruzant 10mg | 10 MG | Invoice | Added July 2019 |
| Q5113** | Inj, herzuma 10mg | 10 MG | Invoice | Added July 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 | |
| Q9954** | Oral MR contrast, 100 ml | 100 ML | Invoice | Added January 2020 |
| Q9955** | Inj perflexane lip micros, ml (Imagent) | 1 ML | Invoice | |
| Q9962** | HOCM 300-349 mg/ml iodine, 1 ml | 1 ML | Invoice | Added January 2020 |
| Q9968** | Inj Non-Radioactive, Non contrast | Invoice | Added January 2020 | |
| Q9969** | Tc-99m from non-highly uranium source | Invoice | Added January 2020 | |
| 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 |
| Q9988** | Platelets, Pathogen Reduced | Invoice | End Date 12/31/2017 | |

