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2019 2nd Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Effective April 1, 2019 through June 20, 2019

Revised: 10.15.19

Unlisted codes A4641, A9698, A9699, J1599, J3490, J3590, J7199, J9999, J7999, Q2039, and Q4100 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 3Q18 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
Alfentanil Hcl   500 mcg $1.485 $1.411  
**Aliqopa (see Copanlisib)          
Allopurinol Sodium   500 mg $2,920.343 $2,774.326  
Alprolix (see Factor IX Fusion Protein Recombinant)          
Amidate (see Etomidate)          
Amino Acid   500 ml $21.110 $20.055  
Amino Acid   1000 ml $35.190 $33.431  
Aminocaproic Acid   250 mg $0.307 $0.292  
**Arginine Hydrochloride (R-Gene 10)   300 ml/30 grams $39.464 $37.491 Updated October 2016 / Updated August 2019
Aripiprazole Lauroxil (Aristada Initio)   1 mg $2.710 $2.575 Added January 2019
**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)          
Atropine Sulfate / Edrophonium Chloride   10 mg $1.651 $1.568  
Avastin (See Bevacizumab)          
Aztreonam   500 mg $13.074 $12.420  
** Bacitracin (Baciim)   50,000 U $6.890 $6.546 Updated August 2019
** Bendamustine (Belrapzo)   1 mg $23.492 $22.317 Added August 2019
** Belrapzo (see Bendamustine)          
Bendamustine Hcl (Bendeka)   1 mg $23.663 $22.480 Added April 2019; Eff. April 2019 use code J9034
Bendeka (see Bendamustine Hcl)          
**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 if 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
Blind Drug Study - Considered Investigational         Added May 2019
Bretylium Tosylate (Bretylol)   5 mg $0.175 $0.166  
Brevibloc (see Esmolol Hydrochloride)          
Bumetanide   0.25 mg $0.293 $0.278  
Bupivacaine   1 ml $0.095 $0.090  
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)          
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)          
**Burosumab-twza (Crysvita) ICD-10 E83.31   10 mg $3,604.000 $3,423.800 Added May 2018
**Bydureon (see Exenatide XR)          
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  
**Cemiplimab-rwlc (Libtayo) - Use J9999 Indicated for the treatment of patients with metastatic cutaneous squamous cell carcinoma (CSCC) or patients with locally advanced CSCC who are not candidates for curative radiation (ICD-10s - C44.02; C44.1121; C44.1122; C44.1291; C44.1292; C44.221; C44.222; C44.229; C44.320; C44.321; C44.329; C44.42; C44.520; C44.521; C44.529; C44.621; C44.622; C44.629; C44.721; C44.722; C44.729; C44.82; C44.92; Z85.828)   50 mg/ml $1,378.000 $1,309.100 Eff 09/28/2018 - Added November 2018
**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 $2.745 $2.608  
Clindamycin Phosphate   150 mg $0.908 $0.863  
Clorpactin WCS-90 (see Oxychlorosene Sodium)          
Coagulation Factor IX, Recombinant (Ixinity)   1 IU 1.406 $1.336 Includes clotting factor furnishing fee
**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 October 2017
Copper Sulfate   0.4 mg $0.125 $0.119  
**Cosentyx- consider self-administered         Added August 2017
**Crysvita (see Burosumab-twza)          
**Cupric Chloride - Non covered by carrier         Added November 2018
Cystografin (see Diatrizoate Meglumine)          
Dantrolene Sodium   20 mg $78.800 $74.860  
**Defibrotide Sodium (Defitelio)   6.25 mg per kg Invoice   Added March 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 $5.447 $5.175 Updated August 2019
** Dextrose 5% / Sodium Chloride   1000 ml $4.912 $4.666 Updated August 2019
Diatrizoate Meglumine (Cystografin)   10 ml $2.100 $2.00  
Diltiazem Hydrochloride   5 mg 0.278 $0.264  
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 $18.405 $17.485  
**Dupilumab (Dupixent) Consider Self-administered          
**Dupixent (see Dupilumab)          
**Edaravone (Radicava) ICD-10 G12.21   30 mg $575.580 $546.801 Added May 2017
Edecrin Sodium (see Ethacrynate Sodium)          
Edrophonium Chloride (Enlon, Tensilon)[ICD-10 G70.00-G70.01]   10 mg $5.653 $5.370  
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          
** Eravacycline (Xerava) For the treatment of Intra-abdominal infections, complicated - As this drug is infused every 12 hours and once reconstituted is viable for 24 hours refrigerated, we suggest saving unused portion of the reconstituted vial for the second infusion to cut down on wastage - Covered ICD-10 codes: A04.0; A04.1; A04.2; A04.3; A04.4; A04.5; A04.6; B95.0; B95.1; B95.2; B95.3; B95.4; B95.61; B95.62; B95.7; B95.8; B96.0; B96.1; B96.2; B96.20; B96.21; B96.22; B96.23; B96.29; B96.3; B96.4; B96.5; B96.6; B96.7; B96.81; B96.82; B96.89   5 mg $5.194 $4.934 Added August 2019;
Eff. Date 05/30/2019
**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 $0.717 $0.681  
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  
**Evenity (see Romosozumab-aqqg)          
**Exenatide XR (Bydureon) Considered Self-administered         Added January 2019
**Factor IX Fusion Protein Recombinant (Alprolix) Furnishing fee included in payment limit   1 IU $3.213 $3.052  
Famotidine   10 mg $0.388 $0.369  
Firazyr (see Icantibant)          
Flagyl IV (see Metronidazole In Nacl.)          
Floxin IV (see Ofloxacin)          
Flumazenil (Mazicon, Romazicon)   0.1 mg $0.973 $0.924  
**Fluocinolone Acetonide, Ocular Implant, Intravitreal Injection (Yutiq) - indicated for chronic noninfectious uveitis affecting the posterior segment of the eye.   .01 mg $491.333 $466.766 Added May 2019
Folic Acid   5 mg $2.296 $2.181  
Fospropofol Disodium injection (Lusedra)   35 mg $1.272 $1.208  
Gammaked injection   500 mg $37.484 $35.610  
Glucarpidase   10 units $313.198 $297.538  
Glycopyrrolate injection   0.2 mg $3.853 $3.660  
**Herceptin Hylecta (see Hyaluronidase-oysk/trastuzumab)          
Hetastarch Sodium Cl., 6 gm/500 ml   6 gm $23.040 $21.888  
**Hyaluronidase-oysk/trastuzumab (Herceptin Hylecta) ICD-10 codes: C07; C08.0; C08.1; C08.9; C15.3; C15.4; C15.5; C15.8; C15.9; C16.0; C16.1; C16.2; C16.3; C16.4; C16.5; C16.6; C16.8; C16.9; C33; C34.01; C34.02; C34.11; C34.12; C34.2; C34.31; C34.32; C34.81; C34.82; C34.91; C34.92; C50.011; C50.012; C50.019; C50.021; C50.022; C50.029; C50.111; C50.112; C50.119; C50.121; C50.122; C50.129; C50.211; C50.212; C50.219; C50.221; C50.222; C50.229; C50.311; C50.312; C50.319; C50.321; C50.322; C50.329; C50.411; C50.412; C50.419; C50.421; C50.422; C50.429; C50.511; C50.512; C50.519; C50.521; C50.522; C50.529; C50.611; C50.612; C50.619; C50.621; C50.622; C50.629; C50.811; C50.812; C50.819; C50.821; C50.822; C50.829; C50.911; C50.912; C50.919; C50.921; C50.922; C50.929; C54.0; C54.1; C54.2; C54.3; C54.8; C54.9; C55; C79.32; C79.49; D37.1; D37.2; D37.3; D37.4; D37.5; D37.8; D37.9; D48.61; D48.62; D49.3; Z80.49; Z85.00; Z85.028; Z85.118; Z85.3   1 ml $991.151 $941.593 Added April 2019
Hydroxocobalamin - Covered when billed with J9305.   1000 mcg/ml $1.212 $1.151  
**Ibalizumab-ulyk (Trogarzo)   1.33 ml $904.586 $859.357 Added April 2018
Icantibant (Firazyr) - Usually considered self-administered          
**Immune Globulin (Panzyga IVIG) - Use NOC code J1599 Covered for Primary humoral immunodeficiency (PI) in patients 2 years of age and older and Chronic immune thrombocytopenia   500 mg $87.980 $83.581 Added October 2019
** 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: August 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)          
**Juvederm - all formulations (see Restylane)         Added September 2018
**Ketalar (see Ketamine Hydrochloride)          
**Ketamine Hydrochloride (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530. Note: Claims will be denied when billed for treatment of depression (F33.0; F33.1; F33.2; F33.3; F33.4; F33..40; F33.41; F33.42; F33.8) as at this time treatment for depression is considered investigational.   10 mg $0.124 $0.117 Updated February 2019
Labetalol Hcl   5 mg $0.177 $0.168  
** 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 - Need statement on claim as to why patient can't take oral form of drug.   100 mcg $111.915 $106.319 Eff. 5/24/2019 - Updated August 2019
**Libtayo (see Cemiplimab-rwlc)          
Lopressor (see Metoprolol Tartrate)          
Lusedra (see Fospropofol Disodium injection)          
**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 $0.188 $0.179  
Metronidazole inj   500 mg $1.172 $1.113  
Miconazole (Monistat IV) 10 mg     Invoice Invoice  
**Mogamulizumab-kpkc (Poteligeo) ICD-10 codes: C84.00; C84.01; C84.02; C84.03; C84.04; C84.05; C84.06; C84.07; C84.08; C84.09; C84.10; C84.11; C84.12; C84.13; C84.14; C84.15; C84.16; C844.17; C84.18; C84.19; C91.50; C91.52   1 mg $200.870 $190.827 Added April 2019
**Mometasone Furoate (Sinuva Sinus Implant) - Covered for ICD-10 code J33.0 for patients 18 years of age or greater when billed with CPT code 31299 - per implant (1350 mcg)   1350 mcg $1,351.500 $1,283.925 Added May 2019
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  
**Neurolytic Solutions (Considered Part of Procedure)          
Nitroglycerin   5 mg $1.138 $1.081  
Nodolo & Tusal (see Sodium Thiosalicylate)          
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow in emergency situations.   1 mg $4.775 $4.536 Updated August 2019
Norcuron (see Vecuronium Bromide)          
Normal Saline (Sterile Water)   50 ml $1.430 $1.359  
Normodyne (see Labetalol Hydrochloride)          
Nulojix (see Beltatacept)          
Ofloxacin (Floxin IV), 20 mg     Invoice Invoice  
Olanzapine short acting intramuscular injection   0.5 mg $1.114 $1.058  
Omacetaxine Mepesuccinate (Synribo) covered indications: ICD-10 C92.10 or C92.12]   3.5 mg $885.100 $840.845  
** Onpattro (see Patisiran)          
Ontak (see Denileukin Difitox)          
Optison     Invoice Invoice  
** Oxychlorosene Sodium (Clorpactin WCS-90)   1 gm $1.850 $1.758  
Paliperidone Palmitate (Invega Trinza)   1 mg $9.185 $8.726  
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.   40 mg $4.511 $4.285  
**Panzyga IVIG (see Immune Globulin)          
**Patisiran (Onpattro) - Covered for the treatment of polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults (ICD-10 E85.1) [Note: For the administration of the drug, use CPT 96365]   10 mg $10,070.000 $9,566.500 Added October 2018
**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)          
**Perlane (see Restylane)         Added September 2018
**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 June 2018
**Plazomicin (Zemdri)   5 mg $3.339 $3.172 Added February 2019
** Polatuzumab Vedotin/Polatuzumab Vedotin-piiq (Polivy) - Covered for Diffuse Large B-cell lymphoma. ICD-10 codes: C83.30; C83.31; C83.32; C83.33; C83.34; C83.35; C83.36; C83.37; C83.38; C83.39; C85.10; C85.11; C85.12; C85.13; C85.14; C85.14; C85.15; C85.16; C85.17; C85.18; C85.19   10 mg $1,135.715 $1,078.929 Added August 2019;
Eff. Date 06/10/2019
Polidocanol (see Asclera)          
** Polidocanol Foam (see Varithena)          
** Polivy (see Polatuzumab Vedotin/Polatuzumab Vedotin-piiq)          
Potassium Acetate   2 meq $0.027 $0.026  
Potassium Phosphate   3 mmol $0.043 $0.041  
**Poteligeo (see Mogamulizumab-kpkc)          
Probuphine System Kit   1 implant $1,311.750 $1,246.163 Added October 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 January 2018
Protonix IV (see Pantoprazole Sodium)          
** R-Gene 10 (see Arginine Hcl.)          
**Radicava (see Edavarone)          
**Ravulizumab-cwvz (Ultomiris) - Covered indication- Paroxysmal nocturnal hemoglobinuria (Marchiafava-Micheli) - ICD-10 code: D59.5   300 mg. $6,788.240 $6,448.828 Added May 2019
Relistor (see Methylnaltrexone Bromide)          
Renu Voice (RENU') ICD-10 J38.00-J38.02, J38.3     Invoice Invoice Added May 2016
**Repatha Sureclick - considered self administered drug         Added August 2018
** Restylane – Should be billed with CPT codes 11950, 11951, 11952 or 11954 and diagnosis codes ICD-10 E88.1 plus B20 (both diagnosis must be on claim to be allowed).   20mg/ml Invoice Invoice Updated September 2018
Revex (see Nalmefene Hydrochloride)          
Rexolate & Arthrolate (see Sodium Thiosalicylate)          
**Riboflavin 5' - phosphate (see Photrexa Viscous or Photrexa Viscous-Photrexa Viscous Kit)         Added June 2018
Rifampin   600 mg $91.923 $87.327  
Robinul (see Glycopyrrolate)          
**Rolapitant (Varubi) Covered when administered IV for chemotherapy-induced nausea and vomiting   166.5 mg $312.700 $297.065 Added January 2018
Romazicon (see Flumazenil)          
**Romosozumab-aqqg (Evenity) Sclerostin inhibitor indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple factors for fracture; or patients who failed or are intolerant to other available osteoprosis therapy.   1.17 ml $967.250 $918.888 Added April 2019/Updated June 2019
Sarracenia Purpura Non-covered by Carrier          
Sensorcaine, Sterile (see Bupivicaine, Sterile)          
**Sinuva Sinus Implant (see Mometasone Furoate)          
Sodium Acetate   2 meq $0.043 $0.041  
** Sodium Bicarbonate, 4.2%   1 ml $1.146 $1.089 Updated August 2019
** Sodium Bicarbonate, 7.5% (NaHC03)   50 ml $15.508 $14.733 Updated August 2019
Sodium Bicarbonate, 8.4% (NaHC03)   50 ml $0.122 $0.116  
Sodium Chloride, Hypertonic (3%-5% infusion)   250 cc $1.575 $1.496  
** Sodium Phosphate   3mmole/1ml $1.993 $1.893 Added August 2017 /
Eff. 4/23/2019 - Updated August 2019
** 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 $0.571 $0.542  
SurgiMend   0.5 sq cm $12.426 $11.805  
Sylatron (peginterferon alfa 2B) considered self administered          
Synribo (see Omacetaxine Mepesuccinate)          
Tagamet (see Cimetidine Hydrochloride)          
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 $105.250 $99.988 Updated with ICD-10. Pricing info EFF: October 2016 Eff:7/3/2018 - updated October 2018
Tetanus Toxoid (use codes 90702, 90703, or 90718)        
**Trace Minerals - Non-covered by carrier         Added May 2019
Trandate (see Labetalol Hydrochloride)          
**Trogarzo (see Ibalizumab-ulyk)          
Truxton (see Prednisolone Acetate)          
**Ultomiris (see Ravulizumab-cwvz)          
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 $165.121 $156.865  
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 100   1 ml $6.505 $6.180 Updated October 2019
** 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
** Xerava (see Eravacycline)          
**Yutiq (see Fluocinolone Acetonide, Ocular Implant, Intravitreal Injection)          
**Zemdri (see Plazomicin)          
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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