2019 4th Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs
Effective October 1, 2019 through December 31, 2019
Revised: 12.26.19
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 4Q19 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 |
|---|---|---|---|---|---|
| ** Adakveo (see Crizanlizumab-twca) | |||||
| Alfentanil Hcl | 500 mcg | $0.875 | $0.831 | td>||
| Allopurinol Sodium | 500 mg | $2,530.659 | $2,404.126 | ||
| Amidate (see Etomidate) | |||||
| Amino Acid | 500 ml | $21.110 | $20.055 | ||
| Amino Acid | 1000 ml | $35.190 | $33.431 | ||
| Aminocaproic Acid | 250 mg | $0.306 | $0.291 | ||
| ** 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 | $2.797 | $2.657 | 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 | $12.687 | $12.053 | ||
| ** Bacitracin (Baciim) | 50,000 U | $6.890 | $6.546 | Updated August 2019 | |
| ** Beovu (see Brolucizumab-dbll) | |||||
| 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) | |||||
| ** Brolucizumab-dbll (Beovu) - indicated for the treatment of Neovascular (Wet) Age-Related Macular Degeneration (AMD). [ICD-10 H35.3210; H35.3211; H35.3212; H35.3213; H35.3220; H35.3221; H35.3222; H35.3223; H35.3230; H35.3231; H35.3232; H35.3233] | 6 mg/0.5 ml | $1,961.000 | $1,862.950 | Added October 2019 | |
| Bumetanide | 0.25 mg | $0.313 | $0.297 | ||
| Bupivacaine | 1 ml | $0.127 | $0.121 | ||
| Bupivacaine Hcl, 0.25%, 2 ml - Considered Part of Procedure | |||||
| Bupivacaine Hcl, 0.50%, 2 ml - Considered Part of Procedure | |||||
| ** Bupivacaine Hydrochloride & Epinephrine Bitartrate (Marcaine/Epinephrine; Marcaine/Epinephrine PF; Sensorcaine-MPF/EPINEPHrine; Sensorcaine/EPINEPHrine) - Considered part of procedure | Added August 2019 | ||||
| ** Bydureon (see Exenatide XR) | |||||
| Calciferol (see Ergocalciferol D2) | |||||
| Calcium Chloride | 100 mg / ml | $0.159 | $0.151 | ||
| ** Candida Albicans | Invoice | Updated October 2019 | |||
| Candida Antigen - Non-covered by carrier. | |||||
| Cardizem IV (see Diltiazem Hydrochloride) | |||||
| 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) | 1 mg | $27.448 | $26.076 | Eff 09/28/2018 - Added November 2018; CMS priced eff July 2019 | |
| ** Cenolate (Vitamin C) (Ascorbic Acid) Non-covered by carrier. | |||||
| 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 | $0.869 | $0.826 | ||
| Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | $1.492 | $1.417 | Includes clotting factor furnishing fee | |
| Copper Sulfate | 0.4 mg | $0.125 | $0.119 | ||
| ** Cosentyx- consider self-administered | Added August 2017 | ||||
| ** Crizanlizumab-tmca (Adakveo) - Indicated to reduce the frequency of vaso-occlusive crises (VOCs) in adults and pediatric patients, aged 16 years and older, with sickle cell disease. (ICD-10s - D57.00; D57.01; D57.211; D57.411; D57.811) | 5 mg | $124.928 | $118.682 | Added December 2019 | |
| ** Cupric Chloride - Non covered by carrier | Added November 2018 | ||||
| ** Cutaquig (see Immune Globulin) | |||||
| 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 | 0.313 | $0.297 | ||
| 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 | $19.045 | $18.093 | ||
| ** Dupilumab (Dupixent) Consider Self-administered | |||||
| ** Dupixent (see Dupilumab) | |||||
| 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. 10/1/2019 - use code J0122 |
|
| ** 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 | $0.345 | $0.328 | ||
| 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 | ||
| Etomidate (Amidate) | 2 mg | $0.617 | $0.586 | ||
| ** Evenity (see Romosozumab-aqqg) | |||||
| ** Exenatide XR (Bydureon) Considered Self-administered | Added January 2019 | ||||
| Famotidine | 10 mg | $0.409 | $0.389 | ||
| Firazyr (see Icantibant) | |||||
| Flagyl IV (see Metronidazole In Nacl.) | |||||
| Floxin IV (see Ofloxacin) | |||||
| Flumazenil (Mazicon, Romazicon) | 0.1 mg | $0.754 | $0.716 | ||
| ** 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 Eff. 10/1/2019 - use code J7314 |
|
| Folic Acid | 5 mg | $2.698 | $2.563 | ||
| Fospropofol Disodium injection (Lusedra) | 35 mg | $1.272 | $1.208 | ||
| Gammaked injection | 500 mg | $37.484 | $35.610 | ||
| Glucarpidase | 10 units | $328.863 | $312.420 | ||
| Glycopyrrolate injection | 0.2 mg | $3.077 | $2.923 | ||
| Hetastarch Sodium Cl., 6 gm/500 ml | 6 gm | $23.040 | $21.888 | ||
| Hydroxocobalamin - Covered when billed with J9305. | 1000 mcg/ml | $1.212 | $1.151 | ||
| Icantibant (Firazyr) - Usually considered self-administered | |||||
| ** Immune Globulin (Cutaquig) | 100 mg | $20.602 | $19.572 | Added December 2019 | |
| ** 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 | |
| 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 | ||||
| ** Kanjinti (see Trastuzumab-anns) | |||||
| ** 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 | $0.210 | $0.200 | ||
| ** 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 | 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 | ||
| ** Marcaine/Epinephrine; Marcaine/Epinephrine PF (see Bupivacaine Hydrochloride & Epinephrine Bitartrate) | |||||
| Mazicon (see Flumazenil) | |||||
| Methylnaltrexone Bromide (Relistor) Non-covered by carrier. | |||||
| Metoprolol Tartrate | 1 mg | $0.197 | $0.187 | ||
| Metronidazole inj | 500 mg | $1.254 | $1.191 | ||
| 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 / CMS priced eff July 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 Eff. 10/1/2019 - use code J7401 |
|
| 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 | ||
| ** Nasal Sprays - Non covered by carrier. | Added August 2019 | ||||
| Netilmicin Sulfate (Netromycin), 150 mg | Invoice | Invoice | |||
| ** Neurolytic Solutions - Considered Part of Procedure | |||||
| Nitroglycerin | 5 mg | $1.185 | $1.126 | ||
| ** 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 | $1.146 | $1.089 | ||
| 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 | |||
| Paliperidone Palmitate (Invega Trinza) | 1 mg | $9.793 | $9.303 | ||
| 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 Eff. 10/1/2019 - use code J0222 |
|
| ** 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 Eff. 10/1/2019 - use code J0291 |
|
| ** 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 | |
| Polidocanol (see Asclera) | |||||
| ** Polivy (see Polatuzumab Vedotin/Polatuzumab Vedotin-piiq) | |||||
| ** Polidocanol Foam (see Varithena) | |||||
| 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 2016 | |
| 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.) | |||||
| ** 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) | |||||
| ** Riboflavin 5' - phosphate (see Photrexa Viscous or Photrexa Viscous-Photrexa Viscous Kit) | |||||
| Rifampin | 600 mg | $105.005 | $99.755 | ||
| Robinul (see Glycopyrrolate) | |||||
| 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./105 mg. | $967.250 | $918.888 | Added April 2019/Updated June 2019 Eff. 10/1/2019 - use code J3111 |
|
| Sarracenia Purpura - Non-covered by carrier. | |||||
| ** Sensorcaine-MPF/EPINEPHrine; Sensorcaine/EPINEPHrine (see Bupivacaine Hydrochloride & Epinephrine Bitartrate) | |||||
| 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 | $1.345 | $1.278 | ||
| ** Sodium Phosphate | 3mmole/1ml | $1.993 | $1.893 | Added August 2017 / Updated August 2019 | |
| ** Sodium Tetradecyl Sulfate (Sotradecol) | 1 ml. | Invoice | Invoice | ||
| Sodium Thiosulfate | 100 mg | $0.155 | $0.147 | ||
| ** Somavert (see Pegvisomant for Injection) | 5 cc | $0.052 | $0.049 | ||
| ** Sotradecol (see Sodium Tetradecyl Sulfate) | |||||
| Stavzor - Non-covered by carrier. | |||||
| Sterile Saline / Water | 1000 ml | $5.640 | $5.358 | ||
| Sulfamethoxazole-Trimethoprim | 400-80mg | $0.588 | $0.559 | ||
| 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) | |||||
| ** Trastuzumab-anns (Kanjinti) 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 | 10 mg | $93.312 | $88.646 | Eff. 7/18/2019 - Added August 2019 Eff. 10/1/2019 - use code Q5117 |
|
| Truxton (see Prednisolone Acetate) | |||||
| ** Tuberculin PPD - when used as an intralesional injection to treat a condition, it's considered investigational. | Added December 2019 | ||||
| ** 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 | |
| Vasopressin | 20 units | $165.466 | $157.193 | ||
| 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 | |||||
| ** Vitamin D injections - Non-covered by carrier. | Added August 2019 | ||||
| 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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