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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  

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