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2015 3rd Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Effective July 1, 2015 through September 30, 2015

Revised: 11.11.15

Unlisted codes J3490, J3590, J9999 and Q9977 billed to the Part B MAC are priced manually. For electronic claims, Loop/Element 2400 SV101-7 must be completed for Not Otherwise Classified (NOC) codes. The required documentation listed below must be submitted in Loop/Element 2400 SV101-7. If additional space is needed, Loop 2400 NTE 02 may be utilized in addition to SV101-7. Paper claims, the documentation must be in Item 19 or as an attachment.

  • Name of the drug
  • NDC number if available
  • Dosage Administered
  • Route of Administration
  • New drugs (WAC information not available and Compounded drugs require invoice information which must be submitted with the claim:

***Note: Effective for dates of service on or after July 1, 2015, claims for compounded drugs must be submitted using HCPCS code Q9977. The name of the drugs in the compound and the invoice information must be included with your claim.

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
Alemtuzumab (Lemtrada)          
Alfentanil Hcl   500 mcg $0.899    
Allopurinol Sodium   500 mg $992.096    
Amidate (see Etomidate)          
Amino Acid    500 ml  $21.110 $20.055  
Amino Acid    1000 ml  $35.190 $33.431  
Aminocaproic Acid   250 mg $0.257    
Arginine Hydrochloride (R-Gene 10)   300 ml $11.225 $10.664  
**Asclera (Polidocanol) ICD-10's I83.001-I83.008, I83.011-I83.018, I83.021-I83.028, I83.11-I83.12, I83.811-I83.813, I83.891-I83.893   5 mg $6.360 $6.042  
** 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   500 mg $12.127    
** 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.   10 mg $31.648 $30.066 Eff 7/1/2014; Dosage change 04/2015
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   0.25 mg $0.259    
Bupivacaine   1 ml $0.078    
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)          
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)          
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 $14.095 $13.390  
Clevidipine Butyrate   1 mg $4.127    
Clindamycin Phosphate   150 mg $1.077    
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   5 mg $0.23    
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 $14.579    
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   10 mg $0.777    
Esomeprazole Sodium   20 mg $11.478    
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   10 mg $0.473 $0.449  
Filgrastim g-csf biosimilar (Zarxio)   1 mcg $0.969 $0.921 Added 03/06/2015 Q5101 Eff 07/01/2015
Firazyr (see Icantibant)          
Flagyl IV (see Metronidazole In Nacl.)          
Floxin IV (see Ofloxacin)          
Flumazenil (Mazicon, Romazicon)    0.1 mg $0.829 $0.788  
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  $2.407 $2.287  
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   0.2 mg $6.384 $6.065  
Hetastarch Sodium Cl., 6 gm/500 ml    6 gm $23.040 $21.888  
Hexaminolevulinate HCL   100 mg, per study dose $881.920 $837.824  
Hydroxocobalamin - Covered when billed with J9305.   1000 mcg/ml $1.212 $1.151  
**HyQvia- ICD-10's C90.00-C90.01, C91.10-C91.12, D59.0-D59.1, D69.3, D69.41, D70.8, D80.0, D80.5, D81.0-D81.2, D81.6-D81.7, D81.89, D82.0, D83.0, D83.2, D83.8-D83.9, G25.82, G35, G61.81, G61.89, G62.89, G64, G70.01, L10.0-L10.5, L10.81, L10.89, L12.0-L12.1, L12.8, L13.8, L14, M30.3, M33.01-M33.02, M33.09, M33.11-M33.12, M33.19, M33.21-M33.22, M33.29, M33.91-M33.92, M33.99, M36.0, T86.01-T86.03, T86.09, T86.11-T86.13, T86.19, Z48.22, Z76.82, Z94.0 DUAL Diagnosis B20 and Z91.89, B20 and Z74.09 or Z78.9, B20 and D69.6, D80.1 and Z92.21   160U/1ml $16.152 $15.344  
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 $38.781    
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 Hcl   5 mg $0.302    
Lemtrada (Alemtuzumab)   1 mg. $1,743.602 $1,656.422 Added April 2015; Code Q9979 effective 10/1/2015
** 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   1 mg $0.136    
Metronidazole inj   500 mg $1.160    
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  
Nitroglycerin IV – Allowed in emergency situations.    5 mg  $0.560 $0.532  
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)   1 mg $25.404 $24.134 Added July 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   0.5 mg $1.293    
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)          Added July 2015
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          
**PEG-Intron (see Peginterferon Alfa 2-B)          
** 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   1 mg $45.692 $43.407 Changed dosage to 1 mg 04/2015
Pepcid (see Famotidine)          
Polidocanol (see Asclera)           
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"   5 mg $53.971 $51.272 Added 05/2014; Added new indications Effective: 12/12/2014; Dosage change 04/2015
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 $120.739    
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  
Sodiun Chloride, Hypertonic (3%-5% infusion)   250 cc $0.924    
** 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   400-80mg $0.473    
SurgiMend   0.5 sq cm $12.555    
Sylatron (see peginterferon alfa 2B)          
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 $31.132    
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 1 mg $17.027 $16.176 Eff 05/01/2014; Dosage change 04/2015
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)          
Zarxio (Filgrastim g-csf biosimilar)          
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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