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2017 1st Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Effective January 1, 2017 through March 31, 2017

Revised: 06.21.17

Unlisted codes J3490, J3590, J9999 and J7999 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 January 1, 2016, claims for compounded drugs must be submitted using HCPCS code J7999. 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)           
Afstyla (Antihemophilic factor(recumb), single chain) Use code J7199   Per I.U. $1.430 $1.359 updated 02/28/2017
Alfentanil Hcl   500 mcg $1.396 $1.326  
Allopurinol Sodium   500 mg $3,427.309 $3,255.944  
Alprolix (see Factor IX Fusion Protein Recombinant)            
**Ameluz (Aminolevulinic Acid Hcl)           
Amidate (see Etomidate)          
Amino Acid    500 ml  $21.110 $20.055  
Amino Acid    1000 ml  $35.190 $33.431  
Aminocaproic Acid   250 mg $0.255 $0.242  
**Aminolevulinic Acid Hcl (Ameluz) Covered for Actinic Keratosis    2 gm $286.200 $271.890 Added March 2017
Antihemophilic factor(recumb), single chain (Afstyla) Use code J7199         updated 02/28/2017
**Antihemophilic Factor(Recumb),Pegylated Lyophilized Powd(Adynovate)    PDS, 1 iu, ea $2.099 $1.994 Eff 01/01/2017: J7207
**Arginine Hydrochloride (R-Gene 10)   300 ml/30 grams $36.538 $34.711 Updated 10/2016
**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) 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  
Atezolizumab (Tecentriq) ICD-10's C33; C34.00; C34.01; C34.02; C34.10; C34.11; C34.12; C34.2; C34.30; C34.31; C34.32; C34.80; C34.81; C34.82; C34.90; C34.91; C34.92; C61; C65.1; C65.2; C65.9; C66.1; C66.2; C66.9; C67.0; C67.1; C67.2; C67.3; C67.4; C67.5; C67.6; C67.7; C67.8; C67.9; C68.0; D09.0; Z85.118;  Z85.51; Z85.89   10 mg $75.702 $71.917 New indications added 10/2016/ Dosage change 10/1/16
Atropine Sulfate / Edrophonium Chloride   10 mg $1.651 $1.568  
Avastin (See Bevacizumab)          
**Avelumab (Bavencio) ( C4A.0; C4A.10; C4A.11; C4A.12; C4A.20; C4A.21; C4A.22; C4A.30; C4A.31; C4A.39; C4A.4; C4A.51; C4A.52; C4A.59; C4A.60; C4A.61; C4A.62; C4A.70, C4A.71; C4A.72; C4A.8; C4A.9)    20 mg $159.424 $151.453 Added 03/2017
**Axumin (See Fluciclovine F-18)          
Aztreonam   500 mg $12.701 $12.066  
** Bacitracin (Bacim)   50,000 U $10.170 $9.662  
**Bavencio (see Avelumab)           
**Bendeka (Bendamustine HCl)          Eff 01/01/2017: J9034
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; E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3591, E08.3592, E08.3593, E09.3211, E09.3212, E09.3213, E09.3291, E09.3292, E09.3293, E09.3311, E09.3312, E09.3313,  E09.3391, E09.3312, E09.3313, E09.3411, E09.3412, E09.3413, E09.3491, E09.3492, E09.3493, E09.3511, E09.3512, E09.3513, E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3591, E10.3592, E10.3593, E11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, E11.3512, E11.3513, E11.3591, E11.3592, E11.3593, E13.3211, E13, 3212, E13.3213, E13.3291, E13.3292, E13.3293, E13.3311, E13.3312, E13.3313, E13.3391, E13.3392, E13.3393, E13.3411, E13.3412, E13.3413, E13.3491, E13.3492, E13.3493, E13.3511, E13.3512, E13.3513, E13.3591, E13.3592, E13.3593, H34.8110, H34.8111, H34.8120, H34.8121, H34.8130, H34.8131, H34.821, H34.822, H34.823, H34.8310, H34.8311, H34.8320, H34.8321, H34.8330, H34.8331, H35.051, H35.052, H35.053, H35.3211, H35.3212, H35.3213, H35.3221, H35.3222, H35.3223, H35.3231, H35.3232, H35.3233, H35.721, H35.722, H35.723, [H32 or H35.81 with one of the following B39.4, B39.5, B39.9] “Note for coverage prior to 10/01/2016 see 2016 3rd Quarter NOC File”    per dose/per eye $60.000   NOTE: For coverage prior to 10/01/2016 see 2016 3rd QTR NOC File Added new ICD-10's 03/30/17
**Bezlotoxumab (Zinplava)  ICD-10  Z29.8 or Z86.19     25 mg/ml $100.700 $95.665  
Bretylium Tosylate (Bretylol)   5 mg $0.175 $0.166  
Brevibloc (see Esmolol Hydrochloride)           
Bumetanide   0.25 mg $0.258 $0.245  
Bupivacaine   1 ml $0.086 $0.082  
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  
**Cinqair (see Reslizumab)           
Clavulanate Potassium / Ticarcillin Disodium   0.1 - 3 gm $14.095 $13.390  
Clevidipine Butyrate   1 mg $3.041 $2.889  
Clindamycin Phosphate   150 mg $0.992 $0.942  
Clorpactin WCS-90 (see Oxychlorosene Sodium)          
Copper Sulfate   0.4 mg $0.125 $0.119  
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      Eff 01/01/2016 Code J0875
Dalvance( see Dalbavancin Hydrochloride)           
Dantrolene Sodium    20 mg  $78.800 $74.860  
Daralex (see Daratumumab)          
Daratumumab (Daralex) ICD-10  C90.00, C90.02   10 mg $46.846 $44.504 Eff 01/01/2017: J9145
**Defibrotide Sodium (Defitelio)   6.25 mg per kg Invoice   Added 03/2016
Defitelio (see Defibrotide Sodium)          
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 $0.186  
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 $18.020 $17.119  
Edecrin Sodium (see Ethacrynate Sodium)          
Edrophonium Chloride (Enlon, Tensilon) (Allow for ICD9—358.0) [ICD-10 G70.00-G70.01]    10 mg $5.653 $5.370 Updated pricing and added name Enlon
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   1 mg $6.250 $5.938 Eff 01/01/2017: J9176
Empliciti (see Elotuzumab)          
Enalaprilat (Vasotec IV)    1.25 mg $1.142 $1.085  
**Entanercept-SZZS (Erelzi) Consider Self-administered          
**Erelzi (Entanercept-SZZS)           
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 $1.027 $0.976  
Esomeprazole Sodium   20 mg $2.233 $2.121  
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  
**Factor IX Albumin Fusion Protein Recombinant (Idelvion) Furnishing fee included in payment limit   1 IU $4.707 $4.472 Eff 01/01/2017: J7202
**Factor IX Fusion Protein Recombinant (Alprolix) Furnishing fee included in payment limit   1 IU $3.213 $3.052  
**Factor X human (Coagadex)  Furnishing fee included in payment limit   1 IU $8.406 $7.986 Eff 01/01/2017: J7175 
Famotidine   10 mg $0.380 $0.361  
Firazyr (see Icantibant)          
Flagyl IV (see Metronidazole In Nacl.)          
Floxin IV (see Ofloxacin)          
**Fluciclovine F-18 (Axumin) ICD-10  Z85.46 billed with CPT codes 78811, 78812, 78813, 78814, 78815, or 78816    Per study dose $3,895.500 $3,700.725 Eff 01/01/2017: A9588
Flumazenil (Mazicon, Romazicon)    0.1 mg $0.752 $0.714  
Flumazenil (Mazicon, Romazicon)    0.5 mg $42.830 $40.689  
Folic Acid     5 mg  $2.733 $2.596  
Fospropofol Disodium injection (Lusedra)   35 mg $1.272 $1.208  
**Gallium ga -68 Dotatate (NETSPOT)    SINGLE DOSE KIT $3,604.000 $3,423.800 Eff 01/01/2017: A9587
Gammaked injection   500 mg $37.484 $35.610  
Glucarpidase   10 units $284.081 $269.877  
Glycopyrrolate   0.2 mg $6.369 $6.051  
**Granisetron Extended Release (Sustol)   10 mg $524.700 $498.465 Added 10/2016
Hetastarch Sodium Cl., 6 gm/500 ml    6 gm $23.040 $21.888  
Hexaminolevulinate Hcl   100 mg, per study dose $959.067 $911.114  
**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 01/01/2017: J7322
Hydroxocobalamin - Covered when billed with J9305.   1000 mcg/ml $1.212 $1.151  
**Hymovis (see Hyaluronic acid)            
Icantibant (Firazyr) - Usually considered self-administered          
Idelvion (see Factor IX Albumin Fusion Protein Recombinant)          
Imlygic (see Talimogene laherparepvec)          
** Inamrinone Lactate   5 mg $4.050 $3.848  
**Inflectra (see Infliximab-dyyb)           
**Infliximab-dyyb (Inflectra) D86.0; D86.1; D86.2; D86.3, D86.81; D86.82; D86.83; D86.84; D86.85; D86.86; D86.87; D86.89; K50.00; K50.011; K50.012; K50.013; K50.014; K50.018; K50.10; K50.111; K50.112; K50.113; K50.114; K50.118; K50.80; K50.811; K50.812; K50.813;K50.814; K50.818; K50.90; K50.911; K50.912; K50.913; K50.914; K50.918; K51.00; K51.011; K51.012; K51.013; K51.014; K51.018; K51.20; K51.211; K51.212; K51.213; K51.214; K51.218; K51.30; K51.311; K51.312; K51.313; K51.314; K51.318; K51.40; K51.411; K51.412; K51.413; K51.414; K51.418; K51.50; K51.511; K51.512; K51.513; K51.514; K51.518; K51.80; K51.811; K51.812; K51.813; K51.814; K51.818; K51.90; K51.911; K51.912; K51.913; K51.914; K51.918; K60.3; K60.4; K60.5; K63.2; L40.0; L40.1; L40.2; L40.3; L40.4; L40.8; L40.51; L40.52; L40.53; L40.54; L40.59; M05.011; M05.012; M05.021; M05.022; M05.031; M05.032; M05.041; M05.042; M05.051; M05.052; M05.061; M05.062; M05.071; M05.072; M05.09; M05.211; M05.212; M05.221; M05.222; M05.231; M05.232; M05.241; M05.242; M05.251; M05.252; M05.261; M05.262; M05.271; M05.272; M05.29; M05.311; M05.312; M05.321; M05.322; M05.331; M05.332; M05.341; M05.342; M05.351; M05.352; M05.361; M05.362; M05.371; M05.372; M05.39; M05.411; M05.412; M05.421; M05.422; M05.431; M05.432; M05.441; M05.442; M05.451; M05.452; M05.461; M05.462; M05.471; M05.472; M05.49; M05.511; M05.512; M05.521; M85.811; M85.812; M85.821; M85.822; M85.831; M85.832; M85.841; M85.842; M85.851; M85.852; M85.861; M85.862; M85.871; M85.872; M85.88; M85.89; M89.211; M89.212; M89.221; M89.222; M89.231; M89.232; M89.233; M89.234; M89.241; M89.242; M89.251; M89.252; M89.261; M89.262; M89.263; M89.264; M89.271; M89.272; M89.28; M89.29; M89.311; M89.312; M89.321; M89.322; M89.331; M89.332; M89.333; M89.334; M89.341; M89.342; M89.351; M89.352; M89.361; M89.362; M89.363; M89.364; M89.371; M89.372; M89.38; M89.39; M89.511; M89.512; M89.521; M89.522; M89.531; M89.532; M89.541; M89.542; M89.551; M89.552; M89.661; M89.662; M89.571; M89.572; M89.58; M89.59; M89.8X0; M89.8X1; M89.8X2; M89.8X3; M89.8X4; M89.8X5; M89.8X6; M89.8X7; M89.8X8; M94.1; M94.351; M94.352; M94.8X0; M94.8X1; M94.8X2; M94.8X3; M94.8X4; M94.8X5; M94.8X6; M94.8X7; M94.8X8   100 mg Invoice Invoice Eff 01/01/2017: Q5102
EFF 04/05/16 see code Q5102 and ZB modifier must be appended. Dosage change from 100mg to 10mg 
Integra Meshed Bilayer Wound Matrix   1 SQ cm $49.211 $46.750 Updated pricing July 2017 per CMS
Invega Trinza    1 MG $8.137 $7.730 Added January 2016
Irinotecan Liposome Inj (Onivyde) ICD-10 C25.0-C25.9   1 mg $39.546 $37.569 Eff 01/01/2017: J9025
Isoproterenol Hydrochloride (Isuprel)    0.2 mg  $2.250 $2.138  
Isoptin IV (see Verapamil Hydrochloride)          
Isuprel (see Isoproterenol Hydrochloride)          
Ixinity   I IU $1.438 $1.366 Added January 2016
**Joint Tunnel and Trigger Kit  (not covered)          
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  
Labetalol Hcl   5 mg $0.161 $0.153  
**Lartruvo (see Olaratumab)           
** 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  
**Magnesium Chloride Injection   1 ml $0.324 $0.308  
Mandol (see Cefamanadole Nafate)          
Mazicon (see Flumazenil)          
**Mepolizumab(Nucala)  ICD-10 J45.5, J45.50    100 mg $2,650.000 $2,517.500 Eff 01/01/2017: J2182
Methylnaltrexone Bromide (Relistor)  Non-covered by carrier.          
Metoprolol Tartrate   1 mg $0.155 $0.147  
Metronidazole inj   500 mg $1.125 $1.069  
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, C33, Z85.118   1 mg $5.276 $5.012 Eff 01/01/2017: J9295
Netilmicin Sulfate (Netromycin), 150 mg     Invoice Invoice  
**NETSPOT (see Gallium ga-68 dotatate)          
Nitroglycerin IV – Allowed in emergency situations.    5 mg  $0.947 $0.900  
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)          
Nucala (see Mepolizumab)          
Nulojix (see Beltatacept)          
**Ocrelizumab (Ovrevus) ICD-10 G35   30 mg $1,722.500 $1,636.375 Added 05/03/2017
**Ocrevus (see Ocrelizumab)          
Ofloxacin (Floxin IV), 20 mg     Invoice Invoice  
Olanzapine short acting intramuscular injection   0.5 mg $1.225 $1.164  
**Olaratumab (Lartruvo) C45.0; C45.1; C45.2; C45.7; C46.1; C46.2; C46.3; C46.4; C46.51; C46.52, C46.7; C47.0; C47.11; C47.12; C47.21; C47.22;  C47.3; C47.4; C47.5; C47.6; C47.8; C47.9; C48.2; C48.1; C48.2; C48.8; C49.0; C49.10; C49.11; C49.12; C49.20; C49.21; C49.22; C49.3; C49.4; C49.5; C49.6; C49.8; C49.9; C49.A1; C49.A2; C49.A3; C49.A4; C49.A5; C49.A9   10 mg $50.032 $47.530 Added 11/02/16
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 (Irinotecan Liposome Inj)          
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)          
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  
Probuphine System Kit   1 implant $1,311.750 $1,246.163 Added 10/01/16
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.)          
Relistor (see Methylnaltrexone Bromide)          
Renu Voice (RENU') ICD-10 J38.00-J38.02 , J38.3     Invoice Invoice added 05/2016
**Reslizumab (Cinqair)  ICD-10  J82   100 mg $885.100 $840.845 Eff 01/01/2017: J2786
Restylane  – Should be billed with CPT codes 11950, 11951, 11952 or 11954 and diagnosis codes Both diagnosis must be on claim to be allowed. ICD-10 E88.1 plus B20       20mg/ml Invoice Invoice  
Revex (see Nalmefene Hydrochloride)          
Rexolate & Arthrolate (see Sodium Thiosalicylate)          
Rifampin   600 mg $122.599 $116.469  
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    2 mg/ml $1,060.000 $1,007.000 Eff 01/01/2017: J2840
Sensorcaine, Sterile (see Bupivicaine, Sterile)          
Sodium Acetate    2 meq $0.043 $0.041  
**Sodium Bicarbonate, 4.2%    1 ml $0.843 $0.801  
** Sodium Bicarbonate, 7.5% (NACH03)   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 $1.436 $1.364  
** 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 $0.760 $0.722  
SurgiMend   0.5 sq cm $12.426 $11.805  
**Sustol (see Granisetron Extended Release)          
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    1 million PFU $46.279 $43.965 Eff 01/01/2017: J9325
Tecentriq (See Atezolizumab)          
Tenormin (see Atenolol)          
Tensilon (see Edrophonium Chloride)          
Testosterone   37.5 mg $0.110 $0.105  
Testosterone Pellets (Testopel) ICD-10 E23.0, E29.1, E30.0    75mg $96.585 $91.756 Updated with ICD-10. Pricing info EFF 10/2016
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   0.1 mg $283.338 $269.171 Eff 01/01/2017: J9352
Trandate (see Labetalol Hydrochloride)          
Truxton (see Prednisolone Acetate)          
**Ustekinumab (Stelara) IV form- ICD-10 K50.00; K50.01; K50.011; K50.012; K50.013; K50.014; K50.018; K50.10; K50.11; K50.111; K50.112; K50.113; K50.114; K50.118; K50.80; K50.81; K50.811; K50.812; K50.813; K50.814; K50.818    1 mg $13.046 $12.394 Added Dec 2016
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)  ICD-10's I83.001-I83.899   1 mg $7.526 $7.150 Added March 2015
Vasopressin   20 units $129.581 $123.102  
Vasotec IV (see Enalaprilat)          
Vecuronium Bromide (Norcuron)   1 mg $0.223 $0.212  
Verapamil Hydrochloride (Isoptin IV)   2.5 mg $7.714 $7.328  
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 (Trabectedin)          
**Zinplava (see Bezlotoxumab)            
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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