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2013 4th Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Effective October 1, 2013 through December 31, 2013

Revised: 06.24.14

Name of Drug and EXACT Dosage Given MUST be in Block 19 (paper), as an Attachement, or Narrative Field (EMC)

Payment allowance limits subject to the ASP methodology are based on 2Q12 ASP data.

Providers should contact their local Medicare contractor processing the claim for the most appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.

** - Carrier Priced

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.

Drug Name	NDC Number	Dosage	Current PAR	Current NON-PAR	Notes
Abatacept (Orencia) The subcutaneous form of abatacept is considered self-administered
Ado-Trastuzumab Emtansine (Kadcyla) covered indications HER2-positive, metastatic breast cancer (174.0-175.9)		1 mg	$29.224	$27.763	Added March 2013
Alfentanil Hydrochloride (Alfenta)		500 mcg/5 ml	$1.028	$0.977
Alglucosidase Alfa (Myozyme)		10 mg
Allopurinol Sodium (Aloprim) ICD-9's 274.9 or 790.6 plus the ICD-9 for the neoplasm. Need name of chemotherapy agent causing the elevation of uric acid and a statement as to why patient can not tolerate oral form of the drug.		500 mg/SDV	$316.389	$300.570
Afinitor (see Everolimus)
Amidate (see Etomidate)
Amino Acid		500 ml	$21.110	$20.055
Amino Acid		1000 ml	$35.190	$33.431
Aminocaproic Acid		250 mg	$0.062	$0.059
Arginine Hydrochloride (R-Gene 10)		300 ml	$11.225	$10.664
Arzerra (see Ofatumumab)
** Ascorbic Acid (Vitamin C) (Cenolate) Non-covered by Carrier
** Atenolol (Tenormin) ICD-9's = 401.0 - 429.9		0.5 mg / ml	$0.800	$0.760
Atropine Sulfate / Edrophonium Chloride		10 mg	$1.651	$1.568
Avastin (See Bevacizumab)
Aztreonam (Azactam)		500 mg	$12.970	$12.322
** Bacitracin (Bacim)		50,000 U	$10.170	$9.662
Belimumab (Benlysta) Covered ICD-9: 710.0		10 mg
Beltatacept (Nulojix) Covered indications: V420 and 075 or 996.52		250 mg.	$978.380	$929.461
Benlysta (see Belimumab)
Berinert (see C1 Esterase Inhibitor)
Bevacizumab (Avastin) CPT 67028 must be on claim or in history; allow if billed with J3490 or J3590 and the ICD-9 requirements from one of the following codes: 115.02, 115.12, 115.92, 362.01 - 362.07 (any), 362.16, 362.35 - 362.37 (any), 362.42, 362.52 or 362.83.		N/A	$60.000	$57.000
Bivigam	59730-6503-01	500 mg	$63.579	$60.400	added June 2013
Bivigam	59730-6502-01	500 mg	$63.579	$60.400	added June 2013
Bretylium Tosylate (Bretylol)		5 mg	$0.175	$0.166
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)		0.25 mg	$0.223	$0.212
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.		0.25% - 1 ml	$0.082	$0.078
Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.		0.50% - 1 ml	$0.082	$0.078
Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.		0.75% - 1 ml	$0.082	$0.078
Cabazitaxel (Jevtana®)		1 mg
Calciferol (see Ergocalciferol D2)
Calcium Chloride		100 mg / ml	$0.159	$0.151
Candida Antigen Non covered by carrier.
Cardizem IV (see Diltiazem Hydrochloride)
Carfilzomib (Kyprolis) covered ICD-9 203.00 or 203.02		1 mg	$29.291	$27.826	Updated April 2013
** Cefamanadole Nafate (Mandol)		1 gm	$8.610	$8.180
** Cefoperazone Sodium (Cefobid)		1 gm	$16.380	$15.561
Cefotetan Disodium (Cefotan)		1 gm	$11.376	$10.807
**Cenolate (Vitamin C) (Ascorbic Acid) Non covered by carrier
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet)		150 mg	$1.064	$1.011
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium		0.1 - 3 gm	$11.886	$11.292
Clevidipine Butyrate		1 mg	$2.815	$2.674
Clindamycin Phosphate (Cleocin)		150 mg	$1.653	$1.570
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate		0.4 mg	$0.125	$0.119
Cystografin (see Diatrizoate Meglumine)
Dantrolene Sodium		20 mg	$78.800	$74.860
Denileukin Difitox (Ontak) (For 300 mcg, use code J9160)		150 mcg	$595.430	$565.659
Depacon (see Valproate Sodium)
Depakene - Non covered by carrier
Depakote Non covered by carrier
Depakote ER - Non covered by carrier
Depakote Sprinkles-Non covered by carrier
Dextrose 2.5%		2.50%	$7.680	$7.296
Dextrose 5%		5%	$7.860	$7.467
Dextrose 10%		500 ml	$10.000	$9.500
Dextrose 50%		50 ml	$0.101	$0.096
** Dextrose / Nitroglycerin 5%-20 mg/ 100 ml/250 ml		20 mg/100 ml/250 ml	$6.320	$6.004
** Dextrose 5% / Sodium Chloride		1000 ml	$11.220	$10.659
Diatrizoate Meglumine (Cystografin)		10 ml	$2.10	$2.00
Diltiazem Hydrochloride (Cardizem IV)		5 mg	$0.187	$0.178
Diprivan (see Propofol)
Divalproex Sodium- Non covered by carrier
Divalproex Sodium ER- Non covered by carrier
Doxapram Hydrochloride (Dopram)		20 mg	$2.195	$2.085
Doxycycline Hyclate		100 mg	$14.520	$13.794
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)		10 mg	$2.420	$2.299
Elaprase (see Idursulfase)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)		1.25 mg	$1.142	$1.085
Eovist (see Gadoxetate Disodium)
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office		500,000 IU/ 1ml	$29.840	$28.348
Eribulin Mesylate (Halaven) - Covered ICD-9's = 174.0 - 174.9		0.1 mg
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 = 427.89 (Dosage change from 100 mg to 10 mg.)		10 mg	$0.772	$0.733
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.		20 MG	$3.559	$3.381
Estradiol		1 gram	$13.300	$12.635
** Estradiol Pellets		Per Pellet	Invoice	Invoice
Ethacrynate Sodium (Edecrin Sodium)		50 mg	$19.040	$18.088
** Ethiodized Oil (Ethiodol)		1 ml	$8.060	$7.657
Etomidate (Amidate)		2 mg	$0.621	$0.590
Everolimus (Afinitor / Zortress) - Non-Covered; Oral drug considered as self-administered.
Famotidine (Pepcid)		10 mg	$0.380	$0.361
Ferric Carboxymaltose (Injectafer) Covered for iron-deficiency anemia: Treatment of iron-deficiency anemia in adults (280.0, 280.8, 280.9, 285.22, or 285.3 plus secondary diagnoses for the condition causing the anemia) with intolerance to oral iron or unsatisfactory response to oral iron (statement must be included on the claim as to why patient needs IV over oral); treatment of iron-deficiency anemia in adults with non-dialysis-dependent chronic kidney disease (Primary DX from one of the following – 280.0, 280.8, 280.9 plus Secondary DX from one of the following – 585.3, 585.4, 585.5)		750mg/15ml	$795.000	$755.250
Firazyr (see Icantibant)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)		0.1 mg	$0.875	$0.831
Flumazenil (Mazicon, Romazicon)		0.5 mg	$42.830	$40.689
Folic Acid		5 mg	$2.075	$1.971
Folotyn (see Pralatrexate)
Fospropofol Disodium injection (Lusedra)		35 mg	$1.272	$1.208
Gammaked injection		500 mg	$37.484	$35.610
Gammaplex (see Human Immune Globulin Intravenous)
Gazyva (see Obinutuzumab)
Glucarpidase		10 units	$244.956	$232.708
Glycopyrrolate (Robinul)		0.2 mg	$0.499	$0.474
Golimumab (See Simponi Aria)
Granix(tm) (tbo-filgrastim) injection		5 MCG	$4.222		Code for 2014- J1446
Halaven (see Eribulin Mesylate)
** Heparin Sodium		100 units	$0.032	$0.030
Hetastarch Sodium Cl., 6 gm/500 ml		6 gm	$23.040	$21.888
Hexaminolevulinate Hydrochloride - Covered for ICD-9's 188.0 through 188.9		100 mg, per study dose	$741.576	$704.497
Hizentra (see Immune Globulin Subcutaneous)
Human Immune Globulin Intravenous (Gammaplex)		IV
Hydroxocobalamin - Covered when billed with J9305.		1000 mcg/ml	$1.212	$1.151
Icantibant (Firazyr) - Usually considered self-administered
Ilaris (see Canakinumab)
Immune Globulin (see Bivigam)	59730-6503-01	100 ml			added June 2013
Immune Globulin (see Bivigam)	59730-6502-01	50 ml			added June 2013
** Inamrinone Lactate		5 mg	$4.050	$3.848
IncobotulinumtoxinA (Xeomin) - Covered for the treatment of Genetic torsion dystonia (333.6) and Blepharospasm (333.81)		1 Unit
Injectafer (See Ferric Carboxymaltose)
INTEGRA™ Bilayer Matrix Wound Dressing - Covered Indications = 757.39, 941.20-941.21, 941.24-941.31, 941.34-941.41, 941.44-941.51, 941.54-941.59, 942.20-942.59, 943.20-943.59, 944.20-944.58, 945.20-945.59, 946.2-946.5, 948.00-948.99		1 sq cm	$29.830	$28.339
Invega® Sustenna® (see Paliperidone Palmitate injection)
Ipilimumab (Yervoy) - Covered for unresectable or metastatic melanoma.		1mg
Isoproterenol Hydrochloride (Isuprel)		0.2 mg	$2.250	$2.138
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
Isuprel (see Isoproterenol Hydrochloride)
Jetrea (See Ocriplasmin)
Jevtana® (see Cabazitaxel)
Kadcyla (see Ado-Trastuzumab Emtansine)					Added March 2013
Kalbitor (see Ecallantide)
Kenalog (see Triamcinolone Acetonide)
Keppra intraveneous (see Levetiracetam)
Ketamine Hydrochloride (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.		10 mg	$0.067	$0.064
Kyprolis (see Carfilzomib)
Krystexxa (see Pegloticase)
Labetalol Hydrochloride (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses.		5 mg	$0.108	$0.103
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76003, 95990, or 96530. Not payable separately when billed with any other procedures		2.5 mg/ml	$0.310	$0.295
** Levophed Bitartrate (see Norepinephrine Bitartrate)
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug.		0.5 mg	$62.010	$58.910
Lidocaine					Code-J2001
Lopressor (see Metoprolol Tartrate)
Lusedra (see Fospropofol Disodium injection)
Magnesium Chloride Hexahydrate-Covered for the correction of hypomagnesemia (275.2) When administered in the physician's office		1 gram	$0.328	$0.311
Mandol (see Cefamanadole Nafate)
Marqibo (see VinCRIStine sulfate Liposome)	20536-0322-01	0.16mg/ml	$10,335.000		Code for 2014: J9371
Mazicon (see Flumazenil)
Methylcobalamin Injection					Code-J3420
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.		1 mg	$0.209	$0.199
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered for ICD-9's= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0-567.9, 599.0-599.9, 615.0-615.9.		500 mg	$0.967	$0.919
Miconazole (Monistat IV) 10 mg			Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium		50 mg	$2.105	$2.000
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)		1 gm	$8.058	$7.655
Nalmefene Hydrochloride (Revex)		10 mcg	$0.276	$0.262
Netilmicin Sulfate (Netromycin), 150 mg			Invoice	Invoice
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency situations.		5 mg	$0.394	$0.374
Nodolo & Tusal (see Sodium Thiosalicylate)
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow in emergency situations.		1 mg	$2.161	$2.053
Norcuron (see Vecuronium Bromide)
Normal Saline (Sterile Water)		50 ml	$1.430	$1.359
Normodyne (see Labetalol Hydrochloride)
Nplate™ (see Romiplostim)
Nulojix (see Beltatacept)
Obinutuzumab (Gazyva) Covered for the treatment of Chronic Lymphocytic Leukemia (CLL) (ICD-9 204.10) in combination with chlorambucil for the treatment of patients with previously untreated CLL – 100mg	50242-0070-01	100 mg	$546.960	$519.612	Added Nov 2013
Ocriplasmin Intraviteral Injection (Jetrea) Covered indication 379.27 (vitreomacular adhesion)		0.125	$1,046.750	$994.413
Ofloxacin (Floxin IV), 20 mg			Invoice	Invoice
Olanzapine short-acting intramuscular injection (Zyprexa IM) Covered indications = 295.01 - 295.84 when administered in the physicians office.		0.5 mg	$1.320	$1.254	Updated July 2014
Omacetaxine Mepesuccinate (Synribo) covered indications 205.10 without having achieved remission, failed remission or 205.12 in relapse		3.5 mg	$885.100	$840.845
Ontak (see Denileukin Difitox)
Optison			Invoice	Invoice
Orencia (see Abatacept)
** Oxychlorosene Sodium (Clorpactin WCS-90)		1 gm	$1.850	$1.758
Ozurdex (see Dexamethasone Intravitreal Implant)
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.		40 mg	$4.511	$4.285
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) Considered self administered
** Peginterferon Alfa-2B, 150mcg Considered self administered
Pegloticase (Krystexxa) When billed with J3490 or J3590, covered for chronic gout, ICD-9's 274.00 through 274.03		1mg
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered
Pepcid (see Famotidine)
Perjeta (see Pertuzumab)
Pertuzumab (Perjeta) Covered ICD-9 174.0 - 175.9		10 mg/ml	$102.114	$97.008
Potassium Acetate		2 meq	$0.027	$0.026
Potassium Phosphate		3 mmol	$0.043	$0.041
Procaine Hydrochloride		1%	$2.360	$2.242
Procaine Hydrochloride		2%	$3.400	$3.230
Propofol (Diprivan)		10 mg	$0.153	$0.145
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
** R-Gene 10 (see Arginine Hcl.)
Radium Ra 223 dichloride (Xofigo), A9699 – Approved FDA indications of castration-resistant prostate cancer (185) plus symptomatic bone metastases (198.5 secondary malignant neoplasm of bone and bone marrow). The patient's records should contain documentation regarding no known visceral metastatic disease		PER TREATMENT DOSE	$12,190.000	$11,580.500	Updated 05/09/2014
Relistor (see Methylnaltrexone Bromide)
Restylane- Should be billed with CPT codes 11950, 11951, 11952 or 11954 and Medical Records. If billed with one of the CPT codes and no Medical Records, deny for lack of documentaion. If billed without one of the CPT codes 11950, 11951, 11952 or 11954, deny as Not Medically Necessary.
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate Human)
Rifampin		600 mg	$47.625	$45.244
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Sarracenia Purpura Non-covered by Carrier
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Simponi Aria (Golimimab) Covered for moderately to severely active Rheumatoid Arthritis (RA) (714.0-714.2, 714.30-714.89) in combination with methotrexate – 2 mg/kg IV over 30 minutes weeks 0 and 4 and then every 8 weeks	57894-0350-01	50 mg	$1,219.000	$1,158.050	Added July 2013; Code for 2014:J1602
Sipuleucel-T (Provenge) ICD-9 = 185		Per infusion (minimum 50 million cells)
Sodium Acetate		2 meq	$0.043	$0.041
** Sodium Bicarbonate, PF (NACH03)		7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)		50 ml	$0.122	$0.116
Sodium Chloride, Hypertonic					Code- J7131
Sodium Hyaluronate/Chrondroitin Sulfate(Viscoat)
** Sodium Tetradecyl Sulfate (Sotradecol)			Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)		50 mg	$0.970	$0.922
Sodium Thiosulfate		100 mg	$0.155	$0.147
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)		5 cc	$0.052	$0.049
Stavzor- Non covered by carrier
Stelara (see Ustekinumab)
Sterile Saline / Water		1000 ml	$5.640	$5.358
** Sterile Saline / Water, 1000 ml		50mcg/ml	$9.810	$9.320
** Sufentanil Citrate (Sufenta) Separate payment allowed when billed with 62310, 62311, 62318, 62319, 76005, 95990, or 96530. If billed with any other procedures, it will be considered part of the procedure and separate payment will not be allowed.
Sulfamethoxazole/Trimethoprim (SMZ-TMP) Documentation as to why the patient needs to be on IV infusion instead of oral medication, must be in block 19 or as an attachment for paper claims or in the notepad for EMC claims.		400 - 80 mg	$0.320	$0.304
SurgiMend		0.5 sq cm	$12.426	$11.805
Synribo (see Omacetaxine Mepesuccinate)
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
Taliglucurase Alfa		10 units	$31.115
Tenormin (see Atenolol)
Tensilon (see Edrophonium Chloride)
Testosterone		37.5 mg	$0.110	$0.105
Testosterone Pellets (Testopel)		75mg	$81.620	$77.539
Testosterone Pellets (Testopel)		75mg	$81.620	$77.539
Tetanus Toxoid (use codes 90702, 90703, or 90718)
Tetracycline			Invoice	Invoice
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Truxton (see Prednisolone Acetate)
Tyvaso (see Treprostinil inhalation)
Vaccinia IVIG (see Human Immune Globulin Intravenous)
Valproate Sodium (Depacon) IV, Covered ICD9's = 345.00 - 345.91, Allowed when administered IV, in the physician's office. (Dosage change from 500 mg to 100 mg)		100 mg	$0.558	$0.530
Valproic Acid- Non covered by carrier
Vasopressin		20 units	$3.514	$3.338
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)		1 mg	$0.206	$0.196
Verapamil Hydrochloride (Isoptin IV)		2.5 mg	$3.167	$3.009
VIBATIV™ (see Telavancin Injection)
Vincristine Sulfate Liposome (Marquibo) covered ICD-9: 204.00-204.02		0.16mg/ml	$10,335.000		Code for 2014: J9371
Viscoat (Sodium Hyaluronate/Chondroitin Sulfate) Non-covered by carrier
** Vitamin B Complex		Up to 3 ml	$0.930	$0.884
** Vitamin C (see Ascorbic Acid) (Cenolate) Non-covered by Carrier
Vivaglobin (see Immune Globulin Subcutaneous)
VPRIV™ (see Velaglucerase alfa for injection)
Wilate (Human coagulation factor VIII (FVIII) and von Willebrand factor (VWF) powder and solvent for solution for injection) Covered ICD-9: 286.4		1 IU VWF:RCO
Xeomin (see IncobotulinumtoxinA)
Xiaflex (see Collagenase Clostridum Histolyticum)
Xofigo (see Radium Ra 223 dichloride )
Xyntha (see Antihemophilic Factor (Recomb) Plasma/Albumin-Free)
Yervoy (see Ipilimumab)
Zaltrap (see Ziv-Aflibercept)
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 - 153.7 or 154.0 - 154.2		1 mg.	$10.829
Zortress (see Everolimus)
Zyprexa IM (see Olanzapine)
HOCM <= 149 MG/ML		1 ml	$0.041	$0.039
HOCM 200 - 249 MG/ML		1 ml	$0.093	$0.088
HOCM 250 - 299 MG/ML		1 ml	$0.100	$0.095
HOCM 300 - 349 MG/ML		1 ml	$0.104	$0.099
HOCM 350 - 399 MG/ML		1 ml	$0.107	$0.102
HOCM >= 400 MG/ML		1 ml	$0.191	$0.181

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