2018 1st Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs
Effective January 1, 2018 through March 31, 2018
Revised: 04.25.19
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 | EFF 01/2018 Code J7210 | |
| Alfentanil Hcl | 500 mcg | $1.094 | $1.039 | ||
| **Aliqopa (see Copanlisib) | |||||
| Allopurinol Sodium | 500 mg | $3,727.400 | $3,541.030 | ||
| 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 | $0.270 | $0.257 | ||
| **Aminolevulinic Acid Hcl (Ameluz) Covered for Actinic Keratosis | 2 gm | $286.200 | $271.890 | EFF 01/2018 Code J7345 | |
| Antihemophilic factor(recumb), single chain (Afstyla) Use code J7199 | updated 02/28/2017 | ||||
| **Aprepitant IV (Cinvanti IV) - Covered for the prevention of acute and delayed nausea/vomiting associated with highly-emetogenic chemotherapy and moderately-emetogenic chemotherapy ICD-10s: R11.0, R11.10, R11.11, R11.2 [plus ICD-10 Z51.11 or Z51.12 must be on the claim]. | 1 mg | $2.405 | $2.285 | added 06/2018 | |
| **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) Not available in IV form in the US (Only oral forms available which would not be billed to the Part B contractors) | |||||
| 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; Z85.59 | 10 mg | $75.643 | $71.861 | EFF 01/01/2018 code J9022; New indications added 07/2017/ Dosage change 10/1/16 | |
| Atropine Sulfate / Edrophonium Chloride | 10 mg | $1.651 | $1.568 | ||
| Avastin (See Bevacizumab) | |||||
| **Avelumab (Bavencio) ICD-10s 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; C67.0; C67.1; C67.2; C67.3; C67.4; C67.5; C67.6; C67.7; C67.8; C67.9; C68.0; C68.1; C68.8; D09.0; Z85.51; Z85.59 | 20 mg | $159.424 | $151.453 | EFF 01/01/2018 code J9023; Added 03/2017/ NEW ICD-10 added 07/2017 | |
| Aztreonam | 500 mg | $13.179 | $12.520 | ||
| ** Bacitracin (Bacim) | 50,000 U | $10.170 | $9.662 | ||
| **Bavencio (see Avelumab) | |||||
| **Benralizumab (FASENRA) Covered as add-on maintenance treatment of severe asthma in adults and children ≥12 years of age with an eosinophilic phenotype - ICD-10 J82 | 30mg/ml | $5,037.236 | $4,785.374 | FDA approved 11/14/17 | |
| **Besponsa (see Inotuzumab Ozogamicin) | |||||
| 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, E09.311, E09.3211, E09.3212, E09.3213, E09.3291, E09.3292, E09.3293, E09.3311, E09.3312, E09.3313, E09.3391, 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, H32, 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, H35.81, H35.051, H35.052, H35.053, H35.3211, H35.3212, H35.3213, H35.3221, H35.3222, H35.3223, H35.3231, H35.3232, H35.3233, H35.351, H35.352, H35.353, H35.721, H35.722, H35.723, H44.2A1, H442A2, H442A3, H44.21, H44.22, H44.23, [If submitting B39.4, B39.5, B39.9 one of the following must be submitted H32 or H35.81] "Note for coverage prior to 10/01/2016 see 2016 3rd Quarter NOC File" |
per dose/per eye billing for injections into both eyes append modifier(s) and bill for 2 units. | $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 Added new ICD-10s 10/01/2017 Removed B39.4, B39.5 and B39.9, 10/10/2017 Added B39.4, B39.5 and B39.9 back on file 01/03/18 Added H35.351, H35.352, and H35.353 07/2018 | ||
| **Bezlotoxumab (Zinplava) ICD-10 Z29.8 or Z86.19 | 25 mg/ml | $100.700 | $95.665 | EFF 01/2018 Code J0565 | |
| Bretylium Tosylate (Bretylol) | 5 mg | $0.175 | $0.166 | ||
| Brevibloc (see Esmolol Hydrochloride) | |||||
| Bumetanide | 0.25 mg | $0.265 | $0.252 | ||
| Bupivacaine | 1 ml | $0.081 | $0.077 | ||
| 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 | ||
| **Cinvanti IV (see Aprepitant IV) | |||||
| Clavulanate Potassium / Ticarcillin Disodium | 0.1 - 3 gm | $14.095 | $13.390 | ||
| Clevidipine Butyrate | 1 mg | $2.653 | $2.520 | ||
| Clindamycin Phosphate | 150 mg | $1.087 | $1.033 | ||
| Clorpactin WCS-90 (see Oxychlorosene Sodium) | |||||
| Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.455 | $1.382 | Added January 2016 | |
| **Copanlisib (Aliqopa) ICD-10s C82.00; C82.01; C82.02; C82.03; C82.04; C82.05; C82.06; C82.07; C82.08; C82.09; C82.10; C82.11; C82.12; C82.13; C82.14; C82.15; C82.16; C82.17; C82.18; C82.19; C82.20; C82.21; C82.22; C82.23; C82.24; C82.25; C82.26; C82.27; C82.28; C82.29; C82.30; C82.31; C82.32; C82.33; C82.34; C82.35; C82.36; C82.37; C82.38; C82.39; C82.40; C82.41; C82.42; C82.43; C82.44; C82.45; C82.46; C82.47; C82.48; C82.49; C82.90; C82.91; C82.92; C82.93; C82.94; C82.95; C82.96; C82.97; C82.98; C82.99; C83.00; C83.09 | 60 mg | 4,452.00 | $4,229.400 | Added 10/2017 | |
| Copper Sulfate | 0.4 mg | $0.125 | $0.119 | ||
| **Cosentyx- consider self-administered | Added 08/2017 | ||||
| Cystografin (see Diatrizoate Meglumine) | |||||
| **Cytarabine Liposome/Daunorubicin Liposome injection (Vyxeos)- C92.00; C92.01; C92.02; C92.A0; C92.A1; C92.A2; C92.60; C92.61; C92.62; C92.90; C92.91; C92.92; C94.6 | 100mg/44mg | 8215.000 | $7,804.250 | Added 08/2017 | |
| 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% | 2.5% | $7.680 | $7.296 | ||
| Dextrose 5% | 5.0% | $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 | 0.205 | $0.195 | ||
| 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 | $17.778 | $16.889 | ||
| **Dupilumab (Dupixent) Consider Self-administered | |||||
| **Dupixent (see Dupilumab) | |||||
| **Durolane (see Hyaluronic acid) | |||||
| **Durvalumab (Imfinzi) ICD-10 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; C67.8; C67.9; C68.0; D09.0, Z85.51; Z85.59 | 10 mg | $73.751 | $70.063 | Added 05/2017/ Added new coverage 02/2018 | |
| **Edaravone (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 | $1.458 | $1.385 | ||
| 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 | $0.409 | $0.389 | ||
| **Fasenra (see Benralizumab) | |||||
| Firazyr (see Icantibant) | |||||
| Flagyl IV (see Metronidazole In Nacl.) | |||||
| Floxin IV (see Ofloxacin) | |||||
| Flucelvax-influenza virus vaccine, quadrivalent, ccIIV4, derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use (Flucelvax, ccIIV4) | 0.5 ml | $22.793 | $21.653 | Use Q2039 for dates of service 08/01/2017 through 12/31/2017. Effective 01/01/2018 forward use new CPT code 90756. | |
| Flumazenil (Mazicon, Romazicon) | 0.1 mg | $0.543 | $0.516 | ||
| Folic Acid | 5 mg | $2.140 | $2.033 | ||
| Fospropofol Disodium injection (Lusedra) | 35 mg | $1.272 | $1.208 | ||
| Gammaked injection | 500 mg | $37.484 | $35.610 | ||
| Glucarpidase | 10 units | $298.281 | $283.367 | ||
| Glycopyrrolate | 0.2 mg | $6.108 | $5.803 | ||
| Granisetron Extended Release (Sustol) | 0.1 mg | $4.883 | $4.639 | Eff 01/01/2018 code J1627 | |
| Hetastarch Sodium Cl., 6 gm/500 ml | 6 gm | $23.040 | $21.888 | ||
| Hexaminolevulinate Hcl | 100 mg, per study dose | $1,035.217 | $983.456 | ||
| **Hyaluronic Acid (Durolane) ICD-10 M17.0; M17.11; M17.12; M17.2; M17.31; M17.32; M17.4; M17.5 | 20 mg | $344.500 | $327.275 | Added 05/2018 | |
| 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 | ||
| **Inotuzumab Ozogamicin (Besponsa) ICD-10 C91.00; C91.01; C91.02 | 0.1 mg | $2,202.444 | $2,092.322 | Eff 08/2017 | |
| 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 (see Coagulation Factor IX, Recombinant) | |||||
| **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 | ||
| **Kymriah (see Tisagenlecleucel) | |||||
| Labetalol Hcl | 5 mg | $0.365 | $0.347 | ||
| **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 statement 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) | |||||
| **Lutathera (see lutetium Lu 177 dotatate) | |||||
| **lutetium Lu 177 dotatate (Lutathera) ICD-10 – C25.4; C74.10; C74.11; C74.12; C74.90; C74.91; C74.92; C75.5; C7A.00; C7A.010; C7A.011; C7A.012; C7A.019; C7A.020; C7A.021; C7A.022; C7A.023; C7A.024; C7A.025; C7A.026; C7A.029; C7A.090; C7A.091; C7A.092; C7A.093; C7A.094; C7A.095; C7A.096; C7A.098; C7A.1; C7A.8; C7B.00; C7B.01; C7B.02; C7B.03; C7B.04; C7B.09; C7B.8; E16.1; E.3; E16.8; E34.0; Z85.020; Z85.030; Z85.840; Z85.060; Z85.07; Z85.110; Z85.230; Z85.858 | 200 MCI | $50,350.000 | $47,832.500 | Added 02/2018 Changed dosage per MR 04/10/18 Added new diagnosis 05/2018 | |
| **Luxturna (see Voretigene Neparvovec-rzyl) | |||||
| 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 | $0.168 | $0.160 | ||
| Metronidazole inj | 500 mg | $1.024 | $0.973 | ||
| 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 | $1.057 | $1.004 | ||
| 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 | EFF 01/01/2018 code J2350 | |
| **Ocrevus (see Ocrelizumab) | |||||
| Ofloxacin (Floxin IV), 20 mg | Invoice | Invoice | |||
| Olanzapine short acting intramuscular injection | 0.5 mg | $1.040 | $0.988 | ||
| 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; C49.3; C49.4; C49.5; C49.6; C49.8; C49.9; C49.10; C49.11; C49.12; C49.20; C49.21; C49.22;C49.A1; C49.A2; C49.A3; C49.A4; C49.A5; C49.A9 | 10 mg | $49.950 | $47.453 | EFF 01/01/2018 code J9285 | |
| 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 | $8.821 | $8.380 | ||
| 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) | |||||
| **Photrexa Viscous or Photrexa Viscous-Photrexa Viscous Kit (Riboflavin 5' - phosphate) This product is considered an integral part of the procedure being performed and not separately reimbursable. | added 06/2018 | ||||
| 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 | ||
| **Prolaryn Gel (last 3 to 6 months)or Prolaryn Gel Plus (longer acting form up to 12 months) for ICD-10 J38.00-J38.02, J38.3 | 1cc | Invoice | Added 01/18 | ||
| 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) | |||||
| **Riboflavin 5' - phosphate (see Photrexa Viscous or Photrexa Viscous-Photrexa Viscous Kit) | added 06/2018 | ||||
| Rifampin | 600 mg | $103.846 | $98.654 | ||
| Rituximab/Hyaluronidase Human (Rituxan Hycela) Covered for Follicular Lymphoma (FL) and Diffuse large B cell lymphoma (DLBCL) B20; C82.00; C82.01; C82.02; C82.03; C82.04; C82.05; C82.06; C82.07; C82.08; C82.09; C82.10; C82.11; C82.12; C82.13; C82.14; C82.15; C82.16; C82.17; C82.18; C82.19; C82.20; C82.21; C82.22; C82.23; C82.24; C82.25; C82.26; C82.27; C82.28; C82.29; C82.30; C82.31; C82.32; C82.33; C82.34; C82.35; C82.36; C82.37; C82.38; C82.39; C82.40; C82.41; C82.42; C82.43; C82.44; C82.45; C82.46; C82.47; C82.48; C82.49; C82.50; C82.51; C82.52; C82.53; C82.54; C82.55; C82.56; C82.57; C82.58; C82.59; C82.60; C82.61; C82.62; C82.63; C82.64; C82.65; C82.66; C82.67; C82.68; C82.69; C82.80; C82.81; C82.82; C82.83; C82.84; C82.85; C82.86; C82.87; C82.88; C82.89; C82.90; C82.91; C82.92; C82.93; C82.94; C82.95; C82.96; C82.97; C82.98; C82.99; C83.00; C83.01; C83.02; C83.04; C83.05; C83.06; C83.07; C83.08; C83.09; C83.10; C83.11; C83.12; C83.13; C83.14; C83.15; C83.16; C83.17; C83.18; C83.19; C83.30; C83.31; C83.32; C83.33; C83.34; C83.35; C83.36; C83.37; C83.38; C83.39; C83.70; C83.71; C83.72; C83.73; C83.74; C83.75; C83.76; C83.77; C83.78; C83.79; C83.80; C83.81; C83.82; C83.83; C83.84; C83.85; C83.86; C83.87; C83.88; C83.89; C83.90; C83.91; C83.92; C83.93; C83.94; C83.95; C83.96; C83.97; C83.98; C83.99; C85.20; C85.21; C85.22; C85.23; C85.24; C85.25; C85.26; C85.27; C85.28; C85.29; C85.80; C85.81; C85.82; C85.83; C85.84; C85.85; C85.86; C85.87; C85.88; C85.89; C88.4; C91.10; C91.12; D36.0; D47.Z1; D47.Z2; R59.0; R59.1; R59.9; Z85.72 | 100 MG | $460.374 | $437.355 | CMS priced 01/2018; Added 07/2017 New Diagnosis codes added 6/2018 | |
| Robinul (see Glycopyrrolate) | |||||
| **Rolapitant (Varubi) Covered when administered IV for chemotherapy-induced nausea and vomiting | 166.5 mg | $312.700 | $297.065 | Added 01/2018 | |
| 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 | $1.450 | $1.378 | ||
| **Sodium Phosphate | 3mmole/1ml | $1.029 | $0.978 | Added 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 | $0.640 | $0.608 | ||
| 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 | 1 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) | |||||
| **Tisagenlecleucel (Kymriah) treatment of patients up to age 25 years with B-cell precursor acute lymphoblastic leukemia (ALL) that is refractory or in second or later relapse.ICD-10 C91.00, C91.02 | each | 503,500.000 | $478,325.000 | EFF 01/2018 Code Q2040 | |
| Trandate (see Labetalol Hydrochloride) | |||||
| **Triamcinolone Acetonide Extended-Release (Zilretta) ICD-10 (M17.0; M17.11; M17.12; M17.2; M17.31; M17.32; M17.4; M17.5) | 32 mg each | $604.200 | $573.990 | Added 01/2018 | |
| 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 | EFF 01/2018 Code J3358 | |
| 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, G40.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 | |
| **Varubi (see Rolapitant) | |||||
| Vasopressin | 20 units | $148.146 | $140.739 | ||
| 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) | |||||
| **Voretigene neparvovec-rzyl (Luxturna) ICD-10 codes: H35.50; H35.52; H35.54 | 0.5 ml | $450,500.000 | $427,975.000 | Added April 2019 | |
| **Vyxeos (see Cytarabine Liposome/Daunorubicin Liposome injection ) | |||||
| **Zilretta (see Triamcinolone Acetonide Extended-Release) | |||||
| **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 |

