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 |

