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2014 1st Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Effective January 1, 2014 through March 31, 2014

Revised: 12.03.14

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
Alfentanil Hydrochloride (Alfenta)    500 mcg/5 ml  $1.468 $1.395  
Allopurinol Sodium (Aloprim) ICD-9's 274.9[ICD-10 M10.9] or  790.6 [ICD-10(E79.0. R78.71, R78.79, R78.89, R79.0, or R79.89)] plus 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 drug.   500 mg/SDV $343.154 $325.996  
Amidate (see Etomidate)          
Amino Acid    500 ml  $21.110 $20.055  
Amino Acid    1000 ml  $35.190 $33.431  
Aminocaproic Acid   250 mg $0.078 $0.074  
Arginine Hydrochloride (R-Gene 10)   300 ml $11.225 $10.664  
** Ascorbic Acid (Vitamin C) (Cenolate) Non-covered by Carrier          
** Atenolol (Tenormin) ICD9’s = 401.0 through 429.9  ICD-10 A18.84, I10, I11.0, I11.9, I12.0, I12.9, I13.0, I13.2, I13.10-I13.11, I15.0-I15.2, I15.8-I15.9, I20.0-I20.1, I20.8, I21.01-I21.02, I21.09, I21.11, I21.19, I21.21,  I21.29, I21.3, I21.4, I22.0-I22.2, I22.8-I22.9, I23.0-I23.8, I24.0-I24.1, I24.8, I25.10, I25.110-I25.111, I25.118-I25.119, I25.2-I25.3, I25.41-I25.42, I25.5-I25.6, I25.700-I25.701, I25.708-I25.709,  I25.710-I25.711, I25.718-I25.719, I25.720-I25.721, I25.728-I25.729, I25.730-I25.731, I25.738-I25.739, I25.750-I25.751, I25.758-I25.759, I25.760-I25.761, I25.768-I25.769, I25.790-I25.791, I25.798-I25.799, I25.810-I25.812, I25.82-I25.84, I25.89, I26.01-I26.02, I26.09, I26.90, I26.92, I26.99, I27.0-I27.2, I27.81-I27.82, I27.89, I27.9, I28.0-I28.1, I28.8-I28.9, I30.0-I30.1, I30.8, I31.0-I31.4, I31.8, I32, I33.0, I33.9, I34.0-I34.2, I34.8, I35.0-I35.2, I35.8, I36.0-I36.2, I36.8, I37.0-I37.2, I37.8, I38, I39, I40.0-I40.1, I40.8-I40.9, I41, I42.0-I42.7, I42.8. I43, I44.0-I44.2, I44.30, I44.4-I44.6, I44.69, I44.7, I45.0, I45.19, I44.30, I44.39, I45.2-I45.6, I45.81, I45.89, I45.9, I46.2, I46.8, I47.0-I47.2, I47.9, I48.0-I48.4, I49.01-I49.02, I49.1-I49.3, I49.40, I49.49, I49.5, I49.8-I49.9, I50.1, I50.20-I50.23, I50.30-I50.33, I50.40-I50.43, I50.9, I51.0-I51.5, I51.7, I51.81, I51.89, I51.9, I52, I97.0, I97.110-I97.111, I97.120-I97.121, I97.130-I97.131, I97.190-I97.191 M32.11-M32.12, N26.2, R00.1 Duel Dx I26.90 or I26.99 with one of T80.0XXA, T81.718A, T81.72XA, or T82.818A
  0.5 mg / ml  $0.800 $0.760  
Atropine Sulfate / Edrophonium Chloride   10 mg $1.651 $1.568  
Avastin (See Bevacizumab)          
Aveed (See Testosterone Undecanoate)          
Aztreonam (Azactam)   500 mg $13.209 $12.549  
** Bacitracin (Bacim)   50,000 U $10.170 $9.662  
Beltatacept (Nulojix) Covered indications: V42.0 and 075 or 996.52 [ICD-10( Z48.22, Z94.0 and B27.00-B27.02, B27.09-B27.12, B27.19, B27.80-B27.82, B27.89-b27.92, B27.99 or T86.820-T86.822, T86.828-T86.829)]   250 mg. $978.380 $929.461  
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.  If criteria not met deny. [ICD-10 (E08.311,E08.319, E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.311, E09.319, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.59, E10.311, E10.319, E10.321, E10329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, H34.811-H34.813, H34.821-H34.823, H34.831-H34.833, H35.051-H35.053, H35.32, H35.721-H35.723, H35.81, or H32 with one of the following B39.4-B39.5, B39.9)]   N/A $60.000 $57.000  
Bretylium Tosylate (Bretylol)   5 mg $0.175 $0.166  
Brevibloc (see Esmolol Hydrochloride)           
Bumetanide (Bumex)    0.25 mg $0.338 $0.321  
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 $0.089 $0.085  
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 $0.089 $0.085  
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 $0.089 $0.085  
Calciferol (see Ergocalciferol D2)          
Calcium Chloride   100 mg / ml $0.159 $0.151  
Candida Antigen   Non covered by carrier.           
Cardizem IV (see Diltiazem Hydrochloride)          
** 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  
Clavulanate Potassium / Ticarcillin Disodium   0.1 - 3 gm $11.855 $11.262  
Clevidipine Butyrate   1 mg $6.073 $5.769  
Clindamycin Phosphate (Cleocin)   150 mg $1.606 $1.526  
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%   5.00% $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 $0.204 $0.194  
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 $14.023 $13.322  
Edecrin Sodium (see Ethacrynate Sodium)          
Edrophonium Chloride (Tensilon) (Allow for ICD9—358.0) [ICD-10 G70.00-G70.01]    10 mg $2.420 $2.299  
**Elosulfase Alfa (Vimizim) Covered indications: mucopolysaccharidosis type IV A (MPS IV A); Morquio A syndrome – ICD-9 277.5 / ICD-10 E76.210    1 mg/ml $226.416 $215.095 Eff: 02/14/14
Enalaprilat (Vasotec IV)    1.25 mg $1.142 $1.085  
Ergocalciferol D2 (Calciferol) Allowed when administered in physician's office for ICD-9 = 579.0 or 579.9. POS = 11. [ ICD-10 K90.0  or K90.9]    500,000 IU/ 1ml $29.840 $28.348  
Esmolol Hydrochloride (Brevibloc) Covered  ICD-9 = 427.89 (Dosage change from 100 mg to 10 mg.) ICD-10 I49.8, R00.1
  10 mg $0.826 $0.785 Dosage changed from 100mg to 10 mg 
Esomeprazole Sodium (Nexium IV) Covered indications = 530.10 - 530.19 or 530.81 [ ICD-10 (K20.0, K20.8-K20.9, K21.0, or K21.9)] when administered in physician's office.    20 MG $5.667 $5.384  
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 $0.617 $0.586  
Famotidine (Pepcid)   10 mg $0.361 $0.343  
Ferric Carboxymaltose (Injectafer) Covered for iron-deficiency anemia: Treatment of iron-deficiency anemia in adults (280.0, 280.8, or 280.9) for patients who are intolerant to oral iron or have had an unsatisfactory response to oral iron; treatment of iron deficiency anemia in adults with non-dialysis dependent chronic kidney disease (285.21). The medical reason the patient needs IV iron in place of oral iron must be clearly documented in the patient’s medical record   1 mg. $1.092 $1.037 Effective July 2014 Corrected Coverage Guidelines
Firazyr (see Icantibant)          
Flagyl IV (see Metronidazole In Nacl.)          
Floxin IV (see Ofloxacin)          
Flumazenil (Mazicon, Romazicon)    0.1 mg $0.938 $0.891  
Flumazenil (Mazicon, Romazicon)    0.5 mg $42.830 $40.689  
Folic Acid     5 mg  $1.636 $1.554  
Fospropofol Disodium injection (Lusedra)   35 mg $1.272 $1.208  
Gammaked injection   500 mg $37.484 $35.610  
Gazyva (see Obinutuzumab)          
Glucarpidase    10 units $245.417 $233.146  
Glycopyrrolate (Robinul)   0.2 mg $0.903 $0.858  
Hetastarch Sodium Cl., 6 gm/500 ml    6 gm $23.040 $21.888  
Hexaminolevulinate Hydrochloride - Covered ICD-9's: 188.0 - 188.9; ICD-10 C67.0-C67.9]                 100 mg, per study dose $806.777 $766.438  
Hydroxocobalamin - Covered when billed with J9305.   1000 mcg/ml $1.212 $1.151  
Icantibant (Firazyr) - Usually considered self-administered          
** Inamrinone Lactate   5 mg $4.050 $3.848  
Injectafer (See Ferric Carboxymaltose)          
Isoproterenol Hydrochloride (Isuprel)    0.2 mg  $2.250 $2.138  
Isoptin IV (see Verapamil Hydrochloride)          
Isuprel (see Isoproterenol Hydrochloride)          
Kenalog (see Triamcinolone Acetonide)          
Ketamine Hydrochloride (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.    10 mg $0.067 $0.064  
Labetalol Hydrochloride (Trandate, Normodyne) - Covered if given IV in the office for control of blood pressure in severe hypertension.  Patient is normally switched to oral for maintainance doses.  ICD-9 = 401.0-405.99. [ICD-10 (I10, I11.0, I11.9, I12.0, I12.9, I13.0, I13.2, I13.10-I13.11, I15.0-I15.2, I15.8-I15.9, N26.2)]   5 mg $0.462 $0.439  
** 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  
Lopressor (see Metoprolol Tartrate)          
Lusedra (see Fospropofol Disodium injection)          
Magnesium Chloride Hexahydrate-Covered for the correction of hypomagnesemia (275.2) – 1 gram equals 1 unit/number of service when administered in the physician’s office
[ ICD-10 E83.41-E83.42, E83.49]
  1 gram $0.328 $0.311  
Mandol (see Cefamanadole Nafate)          
Mazicon (see Flumazenil)          
Methylnaltrexone Bromide (Relistor)  Non-covered by carrier.          
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.    1 mg $0.223 $0.212  
Metronidazole In Nacl. (Flagyl IV) - Covered for ICD9’s = 001.0-009.3,040.0-041.9, 481-482.9, 567.0-567.9, 599.0-599.9, 615.0-615.9 when administered in physicians office. [ ICD-10 A00.0-A00.1, A00.9, A01.01-A01.05, A01.09, A02.0-A02.1, A02.20-A02.25, A02.29, A02.8-A02.9, A03.0-A03.3, A03.8-A03.9, A04.0-A04.9, A05.0-A05.5, A05.8-A05.9, A06.0-A06.7, A06.81-A06.82, A06.89, A06.9, A07.0-A07.4, A07.8-A07.9, A08.0, A08.11, A08.19, A08.2, A08.31-a08.32, A08.39, A08.4, A08.8, A09, A48.0, A48.1-A48.4, A48.51-A48.52, A48.8, A49.01-A49.02, A49.1-A49.3, A49.8-A49.9B95.0-B95.5, B95.61-B95.62, B95.7-B95.8, B96.1, B96.21-B96.23, B96.29, B96.0, B96.3-B96.7, B96.81-B96.82, B96.89, J13, J14, J15.0-J15.1, J15.20, J15.211-J15.212, J15.29, J15.3-J15.6, J15.8-J15.9, J18.1, J20.0- J20.2, K65.0-K65.4, K65.8-K65.9, K67, K68.12, K68.19, K68.9 K90.81, M00.111-M00.112, M00.121-M00.122, M00.131-M00.132, M00.141-M00.142, M00.151-M00.152, M00.161, M00.162, M00.171-M00.172, M00.18-M00.19, M60.009, N13.9, N36.0-N36.2, N36.41-N36.43, N36.5, N36.8-N36.9, N39.0, N39.8-N39.9, N71.0-N71.1, N71.9, R31.0-R31.2, R31.9
  500 mg $1.100 $1.045  
Miconazole (Monistat IV) 10 mg     Invoice  Invoice   
Monistat IV (see Miconazole)          
Morrhuate Sodium    50 mg  $2.105 $2.000  
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  $0.407 $0.387  
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)          
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
Ofloxacin (Floxin IV), 20 mg     Invoice Invoice  
Olanzapine short-acting intramuscular injection (Zyprexa IM) Covered indications = 295.01 - 295.84 when administered in physician's office.   [ICD-10(F20.0-F20.2, F20.5, F20.81, F20.89, F25.0-F25.1, f25.8-F25.9)]   0.5 mg $1.20 $1.140 Updated July 2014
Omacetaxine Mepesuccinate (Synribo) covered indications: 205.10 W/O having achieved remission, failed remission or 205.12 in relapse.   [ ICD-10  C92.10 or C92.12]   3.5 mg $885.100 $840.845  
Ontak (see Denileukin Difitox)          
Optison     Invoice Invoice  
** Oxychlorosene Sodium (Clorpactin WCS-90)   1 gm $1.850 $1.758  
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          
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered          
Pepcid (see Famotidine)          
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  $0.137 $0.130  
Protonix IV (see Pantoprazole Sodium)          
** 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  [ICD-10 C61 Malignant neoplasm of prostate; C79.51 secondary malignant neoplasm of bone; C79.52 Secondary malignant neoplasm of bone marrow]   PER TREATMENT DOSE $12,190.000 $11,580.500 Updated 05/2014
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 attached, deny for lack of documentation. If billed without one of the CPT codes 11950, 11951, 11952 or 11954, deny as Not Medically Necessary.  

  20mg/ml      
Revex (see Nalmefene Hydrochloride)          
Rexolate & Arthrolate (see Sodium Thiosalicylate)          
Rifampin    600 mg  $47.041 $44.689  
Robinul (see Glycopyrrolate)          
Romazicon (see Flumazenil)          
Sarracenia Purpura  Non-covered by Carrier          
Sensorcaine, Sterile (see Bupivicaine, Sterile)          
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 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  
** Somavert (see Pegvisomant for Injection)   5 cc $0.052 $0.049  
Stavzor- Non covered by carrier          
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 $0.347 $0.330  
SurgiMend   0.5 sq cm $12.447 $11.825  
Synribo (see Omacetaxine Mepesuccinate)          
Synthroid (see Levothyroxine Sodium)          
Tagamet (see Cimetidine Hydrochloride)          
Tenormin (see Atenolol)          
Tensilon (see Edrophonium Chloride)          
Testosterone   37.5 mg $0.110 $0.105  
Testosterone Pellets (Testopel)   75mg $81.620 $77.539  
**Testosterone Undecanoate (Aveed) ICD-9 257.2, ICD-10 E29.1   750mg/3ml $874.500 $830.775 Eff:03/2014
Tetanus Toxoid (use codes 90702, 90703, or 90718)          
Trandate (see Labetalol Hydrochloride)          
Truxton (see Prednisolone Acetate)          
Vaccinia IVIG (see Human Immune Globulin Intravenous)          
Valproate Sodium (Depacon) IV, Allowed when administered in the physician's office for following DXs: 345.00 - 345.91.  [ICD-10 (G40.001, G40.009, G40.011, G40.019, G40.101, G40.109, G40.111, G40.119, G40.201, G40.209. G40.211, G40.301, G40.309, G40.311, G40.319, G40.411, G40.419, G40.501, G40.509, G40.801-G40.804, G40.811-G40.814, G40.821-G40.824, G40.89, G40.901, G40.909, G40.911, G40.919, G40.A01, G40.A09, D40.A11, G40.A19, G40.B01, G40.B09, G40.B11, G40.B19)]   100 mg  $0.558 $0.530 Dosage changed from 500mg to 100mg 
Valproic Acid- Non covered by carrier          
Vasopressin    20 units $2.654 $2.521  
Vasotec IV (see Enalaprilat)          
Vecuronium Bromide (Norcuron)   1 mg $0.223 $0.212  
Verapamil Hydrochloride (Isoptin IV)   2.5 mg $3.167 $3.009  
Vimizim (see Elosulfase Alfa)          
** 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)          
Xofigo (see Radium Ra 223 dichloride )          
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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