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2017 2nd Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Effective April 1, 2017 through June 30, 2017

Revised: 08.14.17

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
Afstyla (Antihemophilic factor(recumb), single chain) Use code J7199   Per I.U. $1.430 $1.359 updated 02/28/2017
Alfentanil Hcl   500 mcg $1.469 $1.396  
Allopurinol Sodium   500 mg $3,808.736 $3,618.299  
Alprolix (see Factor IX Fusion Protein Recombinant)          
**Ameluz (see 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 $0.257 $0.244  
**Aminolevulinic Acid Hcl (Ameluz) Covered for Actinic Keratosis   2 gm $286.200 $271.890 Added 03/2017
Antihemophilic factor(recumb), single chain (Afstyla) Use code J7199         updated 02/28/2017
**Arginine Hydrochloride (R-Gene 10)   300 ml/30 grams $36.538 $34.711 Updated 10/2016
**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) 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-10s 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 $75.621 $71.840 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; C65.1; C65.2; C65.9; C66.1; C66.2; C66.9; C68.0; C68.1; C68.8)   20 mg $159.424 $151.453 Added 03/2017/ NEW ICD-10 added 05/10/17
Aztreonam   500 mg $13.203 $12.543  
** Bacitracin (Bacim)   50,000 U $10.170 $9.662  
**Bavencio (see Avelumab)          
Bevacizumab (Avastin) CPT 67028 must be on claim or in history; allow if billed with J3490 or J3590 and the ICD-10 requirements from one of the following codes:[ICD 10; E08.311, 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, E10.311, E10.319, 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, E13.311, E13.319, 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, H44.21, H44.22, H44.23 [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-10s 03/30/2017
Added new ICD-10s 05/15/2017
**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 $0.274 $0.260  
Bupivacaine   1 ml $0.083 $0.079  
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 $2.086 $1.982 Updated July 2017 per CMS
Clindamycin Phosphate   150 mg $1.072 $1.018  
Clorpactin WCS-90 (see Oxychlorosene Sodium)          
Copper Sulfate   0.4 mg $0.125 $0.119  
Cystografin (see Diatrizoate Meglumine)          
Dantrolene Sodium   20 mg $78.800 $74.860  
**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 $2.100 $2.00  
Diltiazem Hydrochloride   5 mg 0.203 $0.193  
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 $18.714 $17.778  
**Durvalumab (Imfinzi) ICD-10 C65.1, C65.2, C66.1, C66.2, C68.0, C68.1, C68.9   10 mg $73.751 $70.063 Added 05/2017
**Edavarone (Radicava) ICD-10 G12.21   30 mg $575.580 $546.801 Added 05/2017
Edecrin Sodium (see Ethacrynate Sodium)          
Edrophonium Chloride (Enlon, Tensilon)[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-10 E76.210
  1 mg/ml $226.416 $215.095 Eff-02/14/2014
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 POS = 11. [ICD-10 K90.0 or K90.9]   500,000 IU/ 1ml $29.840 $28.348  
Esmolol Hydrochloride   10 mg $1.139 $1.082  
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 Fusion Protein Recombinant (Alprolix) Furnishing fee included in payment limit   1 IU $3.213 $3.052  
Famotidine   10 mg $0.394 $0.374  
Firazyr (see Icantibant)          
Flagyl IV (see Metronidazole In Nacl.)          
Floxin IV (see Ofloxacin)          
Flumazenil (Mazicon, Romazicon)   0.1 mg $0.635 $0.603  
Folic Acid   5 mg $2.635 $2.503  
Fospropofol Disodium injection (Lusedra)   35 mg $1.272 $1.208  
Gammaked injection   500 mg $37.484 $35.610  
Glucarpidase   10 units $284.215 $270.004  
Glycopyrrolate   0.2 mg $6.523 $6.197  
Granisetron Extended Release (Sustol)   0.1 mg $5.247 $4.985 Added 10/2016/ Dosage Change/Updated pricing July 2017 per CMS
Hetastarch Sodium Cl., 6 gm/500 ml   6 gm $23.040 $21.888  
Hexaminolevulinate Hcl   100 mg, per study dose $1,033.500 $981.825  
Hydroxocobalamin - Covered when billed with J9305.   1000 mcg/ml $1.212 $1.151  
Icantibant (Firazyr) - Usually considered self-administered          
**Imfinzi (see Durvalumab)          
** Inamrinone Lactate   5 mg $4.050 $3.848  
Integra Meshed Bilayer Wound Matrix   1 SQ cm $55.731 $52.944  
Invega Trinza (see Paliperidone Palmitaite)          
Isoproterenol Hydrochloride (Isuprel)   0.2 mg $2.250 $2.138  
Isoptin IV (see Verapamil Hydrochloride)          
Isuprel (see Isoproterenol Hydrochloride)          
Ixinity   I IU $1.394 $1.324 Added January 2016
**Joint Tunnel and Trigger Kit (not covered)          
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 $0.216 $0.205  
**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 – 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)          
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.          
Metoprolol Tartrate   1 mg $0.182 $0.173  
Metronidazole inj   500 mg $1.116 $1.060  
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 $0.981 $0.932  
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)          
**Ocrelizumab (Ocrevus) ICD-10 G35   30 mg $1,722.500 $1,636.375 Added 05/03/17
**Ocrevus (see Ocrelizumab)          
Ofloxacin (Floxin IV), 20 mg     Invoice Invoice  
Olanzapine short acting intramuscular injection   0.5 mg $1.144 $1.087  
**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: ICD-10 C92.10 or C92.12]   3.5 mg $885.100 $840.845  
Ontak (see Denileukin Difitox)          
Optison     Invoice Invoice  
** Oxychlorosene Sodium (Clorpactin WCS-90)   1 gm $1.850 $1.758  
Paliperidone Palmitate (Invega Trinza)   1 mg $8.132 $7.725  
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)          
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.)          
**Radicava (see Edavarone)          
Relistor (see Methylnaltrexone Bromide)          
Renu Voice (RENU') ICD-10 J38.00-J38.02 , J38.3     Invoice Invoice added 05/2016
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 $111.547 $105.970  
**Rituximab/Hyaluronidase Human (Rituxan Hycela) Covered for Follicular Lymphoma (FL) and Diffuse large B cell lymphoma (DLBCL) C82.01; C82.02; C82.03; C82.04; C82.05; C82.06; C82.07; C82.08; C82.09; C82.11; C82.12; C82.13; C82.14; C82.15; C82.16; C82.17; C82.18; C82.19; C82.21; C82.22; C82.23; C82.24; C82.25; C82.26; C82.27; C82.28; C82.29; C82.31; C82.32; C82.33; C82.34; C82.35; C82.36; C82.37; C82.38; C82.39; C82.41; C82.42; C82.43; C82.44; C82.45; C82.46; C82.47; C82.48; C82.49; C82.51; C82.52; C82.53; C82.54; C82.55; C82.56; C82.57; C82.58; C82.59; C82.61; C82.62; C82.63; C82.64; C82.65; C82.66; C82.67; C82.68; C82.69; C82.81; C82.82; C82.83; C82.84; C82.85; C82.86; C82.87; C82.88; C82.89; ; C82.91; C82.92; C82.93; C82.94; C82.95; C82.96; C82.97; C82.98; C82.99; C83.31; C83.32; C83.33; C83.34; C83.35; C83.36; C83.37; C83.38; C83.39   11.7 ml $6,445.234 $6,122.972 Added 07/2017
**Rituximab/Hyaluronidase Human (Rituxan Hycela) Covered for Chronic Lymphocytic Leukemia (CLL) C91.10; C91.12   13.4 ml $7,365.982 $6,997.683 Added 07/2017
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, 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 $1.337 $1.270  
**Sodium Phosphate- must include enough information         Addes 08/2017
** 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 $0.714 $0.678  
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)          
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)        
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 $12.781 $12.142 Added Dec 2016
Vaccinia IVIG (see Human Immune Globulin Intravenous)          
Valproate Sodium (Depacon) IV, Allowed when administered in the physician's office for following [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-10s I83.001-I83.899   1 mg $7.526 $7.150 Added March 2015
Vasopressin   20 units $136.225 $129.414  
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)          
**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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