2015 4th Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs
Effective October 1, 2015 through December 31, 2015
Revised: 06.06.16
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 |
|---|---|---|---|---|---|
| Adynovate (see Antihemophilic Factor (Recombinant), PEGylated Lyophilized Powder for Solution) | |||||
| Alemtuzumab (Lemtrada) | |||||
| Alfentanil Hcl | 500 mcg | $1.065 | $1.012 | ||
| Allopurinol Sodium | 500 mg | $970.854 | $922.311 | ||
| Amidate (see Etomidate) | |||||
| Amino Acid | 500 ml | $21.110 | $20.055 | ||
| Amino Acid | 1000 ml | $35.190 | $33.431 | ||
| Aminocaproic Acid | 250 mg | $0.253 | $0.240 | ||
| **Antihemophilic Factor (Recumb),Pegylated Lyophilized Powd (Adynovate) | PDS, 1 iu, ea | $2.099 | $1.994 | Added 12/02/2015 | |
| Arginine Hydrochloride (R-Gene 10) | 300 ml | $11.225 | $10.664 | ||
| **Asclera (Polidocanol) ICD-10s 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 | $13.300 | $12.635 | ||
| ** 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. ICD-10 C84.00-C84.09, C84.40-C84.49, C84.60-C84.69, C84.70-C84.79, C86.2, C86.5, C86.6, C91.50, C91.52, Z85.72 | 10 mg | $31.641 | $30.059 | 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 | $0.258 | $0.245 | ||
| Bupivacaine | 1 ml | $0.080 | $0.076 | ||
| 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 Albicans | 1 ml | $29.700 | $28.215 | ||
| 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 | $4.321 | $4.105 | ||
| Clindamycin Phosphate | 150 mg | $1.163 | $1.105 | ||
| 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 | ||
| Daralex (see Daratumumab) | |||||
| **Daratumumab (Daralex) ICD-10 C90.00, C90.02 | 100 mg | $477.000 | $453.150 | Eff 11/16/2015 | |
| 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 | $0.20 | $0.190 | ||
| 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 | $13.933 | $13.236 | ||
| 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 | |
| **Elotuzumab (Empliciti) ICD-10 C90.00, C90.02, C90.10, C90.12, C90.20, C90.22, C90.30, C90.32, Z85.79 | 10 mg | $62.750 | $59.613 | Eff 10/2015 | |
| **Empliciti (See Elotuzumab) | |||||
| 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 | $0.778 | $0.739 | ||
| Esomeprazole Sodium | 20 mg | $10.739 | $10.202 | ||
| 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 | $0.418 | $0.397 | ||
| Firazyr (see Icantibant) | |||||
| Flagyl IV (see Metronidazole In Nacl.) | |||||
| Floxin IV (see Ofloxacin) | |||||
| Flumazenil (Mazicon, Romazicon) | 0.1 mg | $0.610 | $0.580 | ||
| 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 | $2.737 | $2.600 | ||
| Fospropofol Disodium injection (Lusedra) | 35 mg | $1.272 | $1.208 | ||
| Gammaked injection | 500 mg | $37.484 | $35.610 | ||
| Glucarpidase | 10 units | $271.244 | $257.682 | ||
| Glycopyrrolate | 0.2 mg | $6.496 | $6.171 | ||
| Hetastarch Sodium Cl., 6 gm/500 ml | 6 gm | $23.040 | $21.888 | ||
| Hexaminolevulinate Hcl | 100 mg, per study dose | $881.920 | $837.824 | ||
| **Hyaluronic acid (Hymovis) ICD-10 M17.0, M17.10-M17.12, M17.2, M17.30-M17.32, M17.4-M17.5, M17.9 | 1 mg | $17.667 | $16.784 | eff 11/2015 | |
| Hydroxocobalamin - Covered when billed with J9305. | 1000 mcg/ml | $1.212 | $1.151 | ||
| **Hymovis (see Hyaluronic acid) | |||||
| **HyQvia- ICD-10s 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 | Eff 11/01/2015 New Code J1575 eff 01/01/2016 | |
| Icantibant (Firazyr) - Usually considered self-administered | |||||
| Iluvien (Fluocinolone Acetonide Intravitreal implant) | |||||
| Imlygic (see Talimogene laherparepvec) | |||||
| ** Inamrinone Lactate | 5 mg | $4.050 | $3.848 | ||
| Integra Meshed Bilayer Wound Matrix | 1 sq cm | $39.494 | $37.519 | ||
| **Irinotecan Liposome Inj (Onivyde) ICD-10 C25.0-C25.9 | 4.3 mg | $171.720 | $163.134 | Eff 10/2015 | |
| Isoproterenol Hydrochloride (Isuprel) | 0.2 mg | $2.250 | $2.138 | ||
| Isoptin IV (see Verapamil Hydrochloride) | |||||
| Isuprel (see Isoproterenol Hydrochloride) | |||||
| Kanuma (see Sebelipase Alfa) | |||||
| 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 | $0.109 | $0.104 | ||
| 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) | |||||
| **Mepolizumab (Nucala) ICD-10 J45.5, J45.50 | 100 mg | $2,650.000 | $2,517.500 | Eff:10/2015 | |
| Methylnaltrexone Bromide (Relistor) Non-covered by carrier. | |||||
| Metoprolol Tartrate | 1 mg | $0.124 | $0.118 | ||
| Metronidazole inj | 500 mg | $1.117 | $1.061 | ||
| 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 | ||
| Necitumumab (Portrazza) ICD-10 C34.00-C34.92 | 16 mg | $84.800 | $80.560 | Eff 12/2015 | |
| Netilmicin Sulfate (Netromycin), 150 mg | Invoice | Invoice | |||
| Nitroglycerin IV – Allowed in emergency situations. | 5 mg | $0.612 | $0.581 | ||
| 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, C64.1-C64.2, C64.9, C65.1-C65.2, C65.9 | 1 mg | $25.376 | $24.107 | Added July 2015/NEW Code EFF 01/01/2016 J9299 | |
| 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) | 5cc/50ml | $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 | $1.214 | $1.153 | ||
| 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 | ||
| Onivyde (see Irinotecan Liposome Inj) | |||||
| 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: C34.01-C34.02, C34.11-C34.12, C34.2, C34.31-C34.32, C43.0, C43.10-C43.12, C43.20-C43.22, C43.30-C43.39, C43.4, C43.51-C43.59, C43.60-C43.62, C43.70-C43.72, C43.8-C43.9, C69.90-C69.92, C79.31, C80.0, Z85.820 | 1 mg | $45.692 | $43.407 | Changed dosage to 1 mg 04/2015 /New indications aded eff 10/2/2015 | |
| Pepcid (see Famotidine) | |||||
| Polidocanol (see Asclera) | |||||
| Polidocanol Foam (see Varithena) | |||||
| **Portrazza (see Necitumumab) | |||||
| 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 ICD-10 E88.1 plus B20. 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 | $138.765 | $131.827 | ||
| Robinul (see Glycopyrrolate) | |||||
| Romazicon (see Flumazenil) | |||||
| Sarracenia Purpura Non-covered by Carrier | |||||
| **Sebelipase Alfa (Kanuma) ICD-10 E77.0-E77.1, E77.8-E77.9 | 2mg/ml | $1,060.000 | $1,007.000 | Eff:12/08/15 | |
| 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 | $1.303 | $1.238 | ||
| ** 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 | $0.497 | $0.472 | ||
| SurgiMend | 0.5 sq cm | $12.322 | $11.706 | ||
| Sylatron (peginterferon alfa 2B) considered self administered | |||||
| Synribo (see Omacetaxine Mepesuccinate) | |||||
| Synthroid (see Levothyroxine Sodium) | |||||
| Tagamet (see Cimetidine Hydrochloride) | |||||
| **Talimogene laherparepvec (Imlygic) ICD-10 C43.0-C43.9 Initial dose only | 1,000,000pfu/1ml | $46.640 | $44.308 | Eff:10/2015 | |
| **Talimogene laherparepvec (Imlygic) ICD-10 C43.0-C43.9 All subsquent doses | 100,000,000pfu/1ml | $4,664.000 | $4,430.800 | Eff:10/2015 | |
| 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) | |||||
| **Trabectedin (Yondelis) ICD-10 C49, C49.0-C49.1, C49.10-C49.12, C49.2, C49.20-C49.22, C49.3, C49.4, C49.5, C49.6, C49.8, C49.9 | 1mg | $2,862.000 | $2,718.900 | Eff 10/23/2015 | |
| 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 | $86.026 | $81.725 | ||
| 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) | |||||
| **Yondelis (see Trabectedin) | |||||
| 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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