2015 1st Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs
Effective January 1, 2015 through March 31, 2015
Revised: 06.04.15
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 | $1.191 | $1.131 | ||
| Allopurinol Sodium (Aloprim) ICD-9s 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 | $333.338 | $316.671 | ||
| Amidate (see Etomidate) | |||||
| Amino Acid | 500 ml | $21.110 | $20.055 | ||
| Amino Acid | 1000 ml | $35.190 | $33.431 | ||
| Aminocaproic Acid | 250 mg | $0.125 | $0.119 | ||
| Arginine Hydrochloride (R-Gene 10) | 300 ml | $11.225 | $10.664 | ||
| ** Ascorbic Acid (Vitamin C) (Cenolate) Non-covered by Carrier | |||||
| ** Atenolol (Tenormin) ICD9s = 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) | |||||
| Aztreonam (Azactam) | 500 mg | $13.739 | $13.052 | ||
| ** Bacitracin (Bacim) | 50,000 U | $10.170 | $9.662 | ||
| Beleodaq (see Belinostat) | |||||
| Belinostat (Beleodaq) Covered for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL) administered over 30 minutes by intravenous infusion once daily on days 1-5 of a 21-day cycle. Cycles can be repeated until disease progression or unacceptable toxicity. ICD-9 codes 202.70 through 202.78. | 500 mg | $1,590.000 | $1,510.500 | Eff 7/1/2014 | |
| 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)] | per dose/per eye | $60.000 | $57.000 | ||
| Blinatumomab (Blincyto) ICD-9 204.00, 204.02 ICD-10 C91.00, C91.02 | 35 mcg | $3,369.284 | $3,200.820 | Eff:12/16/2014 | |
| Blincyto (see Blinatumomab) | |||||
| Bretylium Tosylate (Bretylol) | 5 mg | $0.175 | $0.166 | ||
| Brevibloc (see Esmolol Hydrochloride) | |||||
| Bumetanide (Bumex) | 0.25 mg | $0.187 | $0.178 | ||
| Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure) | |||||
| Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure) | |||||
| Bupivacaine, Sterile, 0.25%, 0.50%, & 0.75% (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. | 1 ml | $0.078 | $0.074 | ||
| 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 | $13.422 | $12.751 | ||
| Clevidipine Butyrate | 1 mg | $4.240 | $4.028 | ||
| Clindamycin Phosphate (Cleocin) | 150 mg | $1.338 | $1.271 | ||
| Clorpactin WCS-90 (see Oxychlorosene Sodium) | |||||
| Copper Sulfate | 0.4 mg | $0.125 | $0.119 | ||
| Cyramza (see Ramucirumab) | |||||
| Cystografin (see Diatrizoate Meglumine) | |||||
| **Dalbavancin Hydrochloride (Dalvance) Covered indications: 681.00-681.02, 681.10-681.11, 682.0-682.7, 686.00-686.01, 686.09, 686.1, or 686.8. Claim must also include one of the following ICD-9s for the organism causing the infection: 041.00 -041.05, 041.09-041.12, or 041.19 ICD-10 codes : L02.511, L02.512; L03.011, L03.012; L03.021, L03.022; L02.611, L02.612; L03.031, L03.032; L03.041, L03.042; K12.2, L02.01, L03.211; L02.11, L03.221, L03.222; L02.211, L02.212, L02.213, L02.214, L02.215, L02.216; L03.311, L03.312, L03.313, L30.314, L30.315, L03.316, L03.321, L03.322, L03.323, L03.324, L03.325, L03.326; L02.411, L02.412, L02.413, L02.414, L03.111, L03.112, L03.113, L03.114, L03.121, L03.122, L03.123, L03.124; L02.511, L02.512; L02.31. L03.317, L03.327; L02.415, L02.416, L03.115, L03.116, L03.125, L03.126; L02.611, L02.612; L02.811, L02.818, L03.811, L03.818, L03.891, L03.898; L98.3; L08.0 Pyoderma, L88, L08.81-L08.82; L92.8, L98.0; B78.1, E83.2, L08.82. Plus the ICD-10 codes for the organism causing the infection: A49.04, A49.02; A49.1, B95.5, B95.0, B95.1, B95.2, B95.3, B95.4, B95.2; B95.61, B95.62; B95.7; B95.8 |
500 mg | $1,579.40 | $1,500.430 | Eff; 05/23/2014 | |
| Dalvance(see Dalbavancin Hydrochloride) | |||||
| 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 | $0.198 | $0.188 | ||
| 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 | $16.478 | $15.654 | ||
| 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 | ||
| Eloctate | 1 IU | $2.296 | $2.181 | Updated April 2015 | |
| 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-02/14/2014 | |
| Enalaprilat (Vasotec IV) | 1.25 mg | $1.142 | $1.085 | ||
| Entyvio (see Vedolizumab) | |||||
| 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 | $0.686 | $0.652 | 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 | $6.718 | $6.382 | ||
| 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 | $0.376 | $0.357 | ||
| Firazyr (see Icantibant) | |||||
| Flagyl IV (see Metronidazole In Nacl.) | |||||
| Floxin IV (see Ofloxacin) | |||||
| Flumazenil (Mazicon, Romazicon) | 0.1 mg | $1.049 | $0.997 | ||
| Flumazenil (Mazicon, Romazicon) | 0.5 mg | $42.830 | $40.689 | ||
| **Fluocinolone Acetonide Intravitreal implant (Iluvien) Covered for diabetic macular edema – 362.07 (documentation regarding patients having been previously treated with a course of corticosteroids and not having a significant rise in intraocular pressure must be documented in the patient's medical records) – 0.19 mg implant ICD-10 E08.311; E08.321; E08.331; E08.341; E08.351; E09.311; E09.321; E09.331; E09.341; E09.351; E10.311; E10.321; E10.331; E10.341; E10.351; E11.311; E11.321; E11.331 | 0.01mg | $490.947 | $466.400 | EFF:11/2014: Added 02/2015 Dosage changed for 0.19mg to 0.01mg | |
| Folic Acid | 5 mg | $2.314 | $2.198 | ||
| Fospropofol Disodium injection (Lusedra) | 35 mg | $1.272 | $1.208 | ||
| Gammaked injection | 500 mg | $37.484 | $35.610 | ||
| Glucarpidase | 10 units | $257.674 | $244.790 | ||
| Glycopyrrolate (Robinul) | 0.2 mg | $6.622 | $6.291 | ||
| Hetastarch Sodium Cl., 6 gm/500 ml | 6 gm | $23.040 | $21.888 | ||
| Hexaminolevulinate Hydrochloride - Covered ICD-9s: 188.0 - 188.9; ICD-10 C67.0-C67.9] | 100 mg, per study dose | $816.200 | $775.390 | ||
| Hydroxocobalamin - Covered when billed with J9305. | 1000 mcg/ml | $1.212 | $1.151 | ||
| Icantibant (Firazyr) - Usually considered self-administered | |||||
| Iluvien (Fluocinolone Acetonide Intravitreal implant) | |||||
| ** Inamrinone Lactate | 5 mg | $4.050 | $3.848 | ||
| Integra Meshed Bilayer Wound Matrix | 1 SQ CM | $34.009 | |||
| 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 | ||
| Keytruda (see Pembrolizumab) | |||||
| 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 | $0.260 | $0.247 | ||
| ** 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 | $0.150 | $0.143 | ||
| Metronidazole In Nacl. (Flagyl IV) - Covered for ICD9s = 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 | $0.955 | $0.907 | ||
| 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 | $0.545 | $0.518 | ||
| **Nivolumab (Opdivo) ICD-9 162.0-162.9, 172.0-172.9, 198.3, 199.0, 199.1 [ICD-10 C43.0-C43.9, C79.31, C80.0, C45.9, C33, C34.00-C34.02, C34.10-C34.12, C34.2, C34.30-C34.32, C34.80-C34.82, C34.90-C34.92)] | 10mg/ml | $254.188 | $241.479 | Eff: 12/2014 Added 03/2015 | |
| 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) | |||||
| 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 | $1.23 | $1.167 | ||
| 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) | |||||
| Opdivo (see Nivolumab) | |||||
| Optison | Invoice | Invoice | |||
| Orbactiv (see Oritavancin Diphosphate) | |||||
| **Oritavancin Diphosphate (Orbactiv) Indicated for treatment of adult patients with acute bacterial skin and skin structure infections by designated susceptible strains of gram-positive microorganisms and should only be used to treat infections that are proven or strongly suspected to be caused by susceptible bacteria. Covered indications: 681.00-681.02, 681.10-681.11, 682.0-682.7, 686.00-686.01, 686.09, 686.1, or 686.8. Patients medical records must include information regarding the organism causing the infection. ICD 10 L02.511, L02.512; L03.011, L03.012; L03.021, L03.022; L02.611, L02.612; L03.031, L03.032; L03.041, L03.042; K12.2, L02.01, L03.211; L02.11, L03.221, L03.222; L02.211, L02.212, L02.213, L02.214, L02.215, L02.216; L03.311, L03.312, L03.313, L30.314, L30.315, L03.316, L03.321, L03.322, L03.323, L03.324, L03.325, L03.326; L02.411, L02.412, L02.413, L02.414, L03.111, L03.112, L03.113, L03.114, L03.121, L03.122, L03.123, L03.124; L02.511, L02.512; L02.31. L03.317, L03.327; L02.415, L02.416, L03.115, L03.116, L03.125, L03.126; L02.611, L02.612; L02.811, L02.818, L03.811, L03.818, L03.891, L03.898; L98.3; L08.0 Pyoderma, L88, L08.81-L08.82; L92.8, L98.0; B78.1, E83.2, L08.82. | 10MG | $25.617 | $24.336 | EFF:09/15/2014: Added 02/2015 | |
| ** 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 | |||||
| Pembrolizumab (Keytruda) Covered indications: Malignant melanoma of the skin: ICD-9 codes = 172.0-172.8 [ICD 10: C43.0 skin of lip, C43.10-C43.12 eyelids including canthus, C43.20-C43.22 skin of ears and external auricular canal, C43.30-C43.39 skin of nose and other parts of face, C43.4 skin of scalp and neck, C43.51-C43.59 anal skin, skin of breast, other part of trunk, C43.60-C43.62 upper limbs including shoulders, C43.70-C43.72 lower limbs including hips, C43.8 overlapping sites of skin; D03.0, D03.10-D03.12, D03.20-D03.22, D03.30, d03.39, D03.4, D03.51-D03.59, D03.60-D03.62, D03.70-D03.72, D03.8 | 100 mg | $4,574.960 | $4,346.212 | Added September 2014/ Changed dosage to 100 mg | |
| Pepcid (see Famotidine) | |||||
| Polidocanol Foam (see Varithena) | |||||
| 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 | ||
| Protonix IV (see Pantoprazole Sodium) | |||||
| ** R-Gene 10 (see Arginine Hcl.) | |||||
| Ramucirumab (Cyramza)- Covered for use as a single agent for the treatment of patients with advanced or metastatic, gastric or gastro esophageal junction (GEJ) adenocarcinoma with disease progression on or after prior treatment with fluoropyrimidine - or platinum-containing chemotherapy (ICD-9: 151.0 through 151.9, 230.1 or 230.2 ICD-10 C16.0-C16.9, D00.1 or D00.2). In combination with docetaxel, is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) with disease progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving CYRAMZA. 162.2-162.5 or 162.8-162.9. ICD-10 C34.00-C34.02; C34.10-C34.12; C34.2; C34.30-C34.32; C34.80-C34.82; C34.90-C34.92 | 10 mg | $108.120 | $102.714 | Added 05/2014: Added new indications EFF:12/12/2014 | |
| Relistor (see Methylnaltrexone Bromide) | |||||
| Restylane – Should be billed with CPT codes 11950, 11951, 11952 or 11954 and diagnosis codes 272.6 plus 042. Both diagnosis must be on claim to be allowed. |
20mg/ml | Invoice | Invoice | ||
| Revex (see Nalmefene Hydrochloride) | |||||
| Rexolate & Arthrolate (see Sodium Thiosalicylate) | |||||
| Rifampin | 600 mg | $68.900 | $65.455 | ||
| 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 Chloride, Hypertonic (3%-5% infusion) | 250 cc | $0.821 | $0.780 | ||
| ** 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 | $0.494 | $0.469 | ||
| SurgiMend | 0.5 sq cm | $12.495 | $11.870 | ||
| 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 | ||
| 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 | |||||
| **Varithena (Polidocanol foam) | 1 mg | $7.526 | $7.150 | Added March 2015 | |
| Vasopressin | 20 units | $4.032 | $3.830 | ||
| Vasotec IV (see Enalaprilat) | |||||
| Vecuronium Bromide (Norcuron) | 1 mg | $0.223 | $0.212 | ||
| Vedolizumab (Entyvio) Covered indications: Adult Ulcerative Colitis (UC) 556.1, 556.2. 556.3, 556.5, or 556.6; also covered for Adult Crohn's Disease (CD) 555.0, 555.1, or 555.2 Adult Ulcerative Colitis: K51.80, K51.20, K51.211, K51.212, K51.213, K51.214, K51.218, K51.219, K51.30, K51.311, K51.312, K51.313, K51.314, K51.318, K51.319, K51.50, K51.511, K51.512, K51.513, K51.514, K51.518, K51.519, K51.00, K51.011, K51.012, K51.013, K51.014, K51.018, K51.019 Adult Crohn's Disease: K50.00, K50.011, K50.012, K50.013, K50.014, K50.018, K50.019, K50.10, K50.111, K50.112, K50.113, K50.114, K50.118, K50.119, K50.80, K50.811, K50.812, K50.813, K50.814, K50.818, K50.819 |
64764-0300-0 | 300 mg | $5,108.140 | $4,852.733 | Eff 05/01/2014 |
| 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) | |||||
| 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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