Skip to Main Content

Print | Bookmark | Font Size: + |

2020 1st Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Effective January 1, 2020 through March 31, 2020

Revised: 06.24.20

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 1Q20 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
** Abatacept (Orencia) - Considered Self-Administered.         Added January 2020 / Use code J0129 for IV infusion only
** ABX-GEF drug study - Medicare does not cover this service.          
** Actiq (see Fentanyl Citrate)          
** Adakveo (see Crizanlizumab-twca)  
** Adalimumab-adaz (Hyrimoz) - Considered Self-Administered.         Added January 2020
** Adalimumab-adbm (Cyltezo) - Considered Self-Administered.         Added January 2020
** Adalimumab-atto (Amjevita) - Considered Self-Administered.         Added January 2020
** Adalimumab-bwwd (Hadlima) - Considered Self-Administered.         Added January 2020
** Aimovig (see Erenumab-aooe)          
** Albiglutide (Tanzeum) - Considered Self-Administered.         Added January 2020
** Alpha Lipoic Acid - Medicare does not cover this service.         Added February 2020
Alfentanil Hcl (Alfenta)   500 mcg $1.269 $1.206  
** Alirocumib (Praluent) - Considered Self-Administered.         Added January 2020
Allopurinol Sodium (Aloprim) - [ICD-10: E79.0, M10.9, R78.71, R78.79, R78.89, R79.0, or R79.89]   500 mg $2,576.822 $2,447.981 Updated January 2020
** Alprostadil/Papaverine/Phentolamine (Tri-Mix) - Considered Self-Administered.         Added January 2020
** Alprostadil/Papaverine/Phentolamine/Atropine (Quad-Mix) - Considered Self-Administered.         Added January 2020
** Alprostadil Phento Mes Papaverine hcl - Considered Self-Administered.         Added January 2020
** Amicar - Considered Self-Administered.         Added January 2020
Amidate (see Etomidate)          
Amino Acid   500 ml $21.110 $20.055  
Amino Acid   1000 ml $35.190 $33.431  
Aminocaproic Acid   250 mg $0.282 $0.268  
** Amjevita (see Adalimumab-atto)          
** Anakinra (Kineret) - Considered Self-Administered.         Added January 2020
** Arginine Hydrochloride (R-Gene 10)   300 ml/30 grams $39.464 $37.491 Updated October 2016 / Updated August 2019
** Argyrol - Considered Part of Procedure.         Added January 2020
** Asclera (Polidocanol) - [ICD-10: 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) - Medicare does not cover this service.          
** Asfotase-alfa (Strensiq) - Considered Self-Administered.         Added January 2020
** Astringyn Solution - Medicare does not cover this service.         Added January 2020
** 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 (Azactam)   500 mg $12.497 $11.872  
** Bacitracin (Baciim)   50,000 U $6.890 $6.546 Updated August 2019
** Becicizmn   No Source Available Invoice Invoice Added January 2020
** 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
** BMS Study Drug - Medicare does not pay for this service.         Added January 2020
Bretylium Tosylate (Bretylol)   5 mg $0.175 $0.166  
Brevibloc (see Esmolol Hydrochloride)          
** Brevital (see Methohexilate)          
** Brodalumab (Siliq) - Considered Self-Administered.         Added January 2020
** Brompton's Cocktail - Considered Self-Administered.         Added January 2020
** 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]   1 mg $317.583 $301.704 Added October 2019
Eff. 1/1/2020 use code J0179
Bumetanide (Bumex)   0.25 mg $0.329 $0.313  
Bupivacaine, Sterile 0.25%, 0.50% & 0.75% (Marcaine Hydrochloride, Sterile; Sensorcaine, Sterile) CPT 51700, 51720, 62310, 62318, 62319, 62368, 62369, 62370, 64400-64484, 64505-64530, 77003, 95990, or 96530 must be on claim or in history.   1 ml $0.090 $0.086 Updated January 2020
Bupivacaine Hcl, 0.25%, 2 ml (Marcaine Hydrochloride; Sensorcaine) - Considered Part of Procedure.          
Bupivacaine Hcl, 0.50%, 2 ml (Marcaine Hydrochloride; Sensorcaine) - 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
Buscopan (see Hyoscine or Scopolamine)          
** Bydureon (see Exenatide XR)          
** Byetta (see Exenatide)          
Calciferol (see Ergocalciferol D2)          
Calcium Chloride   100 mg / ml $0.159 $0.151  
** Candida Albicans   Invoice     Updated October 2019
Candida Antigen - Considered Part of Procedure.          
Cardizem IV (see Diltiazem Hydrochloride)          
Cefotetan Disodium (Cefotan)   1 gm $11.376 $10.807  
** Cell Cept - Must be billed to DMAC.         Added January 2020
** Cenolate (Vitamin C) (Ascorbic Acid) - Medicare does not pay for this service.          
** Cephradine - Considered Self-Administered.         Added January 2020
** Chorionic Gonadotropin Alfa, Recombinant (Ovidrel) - Considered Self-Administered.         Added January 2020
Cimetidine Hcl. (Tagamet)   150 mg $1.064 $1.011  
** Cineraria eye drops - physician's office: Considered Part of Procedure, taken home: Considered Self-Administered.         Added January 2020
Clavulanate Potassium / Ticarcillin Disodium (Timentin)   0.1 - 3 gm $14.095 $13.390  
Clevidipine Butyrate (Cleviprex)   1 mg $2.745 $2.608  
Clindamycin Phosphate (Cleocin)   150 mg $0.800 $0.760  
** Clorafed - Medicare does not pay for this service.         Added January 2020
Coagulation Factor IX, Recombinant (Ixinity)   1 IU $1.653 $1.570 Includes clotting factor furnishing fee
** Colyte Flavored - Medicare does not pay for this service.         Added January 2020
Copper Sulfate   0.4 mg $0.125 $0.119  
** Cosentyx (see Secukinumab)        
** 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 - Must be billed to DMAC.         Added November 2018
Cutaquig (see Immune Globulin)          
** Cyltezo (see Adalimumab-adbm)          
Cystografin (see Diatrizoate Meglumine)          
Dantrolene Sodium   20 mg $78.800 $74.860  
** Defibrotide Sodium (Defitelio) [ICD-10: K76.5]   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 IV)          
Depakene - Considered Self-Administered.          
Depakote - Considered Self-Administered.          
Depakote ER - Considered Self-Administered.          
Depakote Sprinkles - Considered Self-Administered.          
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 (Cardizem IV)   5 mg 0.332 $0.315  
Divalproex Sodium - Considered Self-Administered.          
Divalproex Sodium ER - Considered Self-Administered.          
Doxapram Hydrochloride (Dopram)   20 mg $2.195 $2.085  
Doxycycline Hyclate   100 mg $18.215 $17.304  
** Dulaglutide (Trulicity) - Considered Self-Administered.         Added January 2020
** 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  
** Egrifta (see Tesamorelin)          
** Elmiron - Considered Self-Administered.         Added January 2020
** Emgality (see Galcanezumab-gnlm)          
Enalaprilat (Vasotec IV)   1.25 mg $1.142 $1.085  
** Enfortumab Vedotin-ejfv (Padcev) - [ICD-10s: C61; C65.1; C65.2; C65.9; C66.1; C66.2; C66.9; C67.0; C67.1; C67.2; C67.3; C67.4; C67.6; C67.7; C67.8; C67.9; C68.0; D09.0; Z85.51; Z85.9]   1.25 mg $139.788 $132.799 Added March 2020
** Enhertu (see Fam-Trastuzumab Deruxtecan-nxki)          
** Ephedrine - Considered Part of Procedure.         Added January 2020
** Eptinezumab-jjmr (Vyepti) - [ICD-10: G43.001; G43.009; G43.011; G43.019; G43.101; G43.109; G43.111; G43.119; G43.401; G43.409; G43.411; G43.419; G43.501; G43.509; G43.511; G43.519; G43.601; G43.609; G43.611; G43.619; G43.701; G43.709; G43.711; G43.719]   100 mg $1,584.700 $1,505.465 Eff. 2/21/2020 - Added June 2020
** Erelzi (Etanercept-szzs)          
** Erenumab-aooe (Aimovig) - Considered Self-Administered.         Added Janaury 2020
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 (Brevibloc) - physician's office: [ICD-10: I49.8, R00.1]; during surgery: Considered Part of Procedure.   10 mg $0.331 $0.314  
Esomeprazole Sodium (Nexium IV) Allowed when administered in physician's office [ICD-10: K20.0, K20.8-K20.9, K21.0, or K21.9]   20 mg $2.233 $2.121  
Estradiol   1 gram $13.300 $12.635  
** Estradiol Pellets - Use J3490 for the pellets and 11980 for the administration of the pellets.   Per Pellet Invoice Invoice  
** Estradiol Vaginal Ring (Estring) - Medicare does not pay for this service.        
** Estradurin (see Polyestradiol Phosphate)          
** Estring (see Estradiol Vaginal Ring)          
** Estrogen Pellets (see Estradiol Pellets)          
** Etanercept-szzs (Erelzi) Considered Self-Administered.          
Ethacrynate Sodium (Edecrin Sodium)   50 mg $19.040 $18.088  
** Ethyl Chloride Topical Anesthetic - Considered Part of Procedure.         Added January 2020
Etomidate (Amidate)   2 mg $0.617 $0.586  
** Evolocumab (Repatha,Repatha Sureclick) - Considered Self-Administered.         Added January 2020
** Excedrin - Considered Self-Administered.         Added January 2020
** Exenatide (Byetta) - Considered Self-Administered.         Added January 2020
** Exenatide XR (Bydureon) Considered Self-Administered.         Added January 2019
** Fam-Trastuzumab Deruxtecan-nxki (Enhertu) [ICD-10: 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, or Z85.3]   100 mg $2,436.908 $2,315.063 Added March 2020
Famotidine (Pepcid)   10 mg $0.394 $0.374  
** Fentanyl Citrate (Actiq) Lozenge on a stick - Considered Self-Administered.         Added January 2020
Firazyr (see Icantibant)          
Flagyl IV (see Metronidazole In Nacl.)          
Floxin IV (see Ofloxacin)          
Flumazenil (Mazicon, Romazicon)   0.1 mg $0.619 $0.588  
Folic Acid    5 mg $2.669 $2.536  
** Folvite - Medicare does not pay for this service.         Added January 2020
Fospropofol Disodium injection (Lusedra)   35 mg $1.272 $1.208  
** Galcanezumab-gnlm (Emgality) - Considered Self-Administered.         Added January 2020
** GI Cocktail - Considered Part of Procedure.         Added January 2020
Glucarpidase (Voraxaze)   10 units $328.863 $312.420  
** Glutathione - Considered Self-Administered.         Added January 2020
** Glycerin solution (all percentages) - Medicare does not pay for this service.         Added January 2020
Glycopyrrolate injection (Robinul)   0.2 mg $3.065 $2.912  
** Golimumab Non-IV form (Simponi Non-IV form) - Considered Self-Administered.         Added January 2020
** Hadlima (see Adalimumab-bwwd)          
** Healon - Considered Part of Procedure.         Added January 2020
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  
** Hydrochloric Acid - billed with another code on same DOS: Considered Part of Procedure. Billed alone: invoice   No Source Available Invoice Invoice Added January 2020
** Hydroxyzine Pamoate - Considered Self-Administered.         Added January 2020
** Hyoscine or Scopolamine (Buscopan)   1 mg $21.068 $20.015 Added June 2020
** Hyrimoz (see Adalimumab-adaz)          
** Ibuprofen - Considered Part of Procedure.         Added January 2020
Icantibant (Firazyr) - Considered Self-Administered.          
Immune Globulin (Cutaquig)   100 mg $16.422 $15.601 Added January 2020
Immune Globulin (Panzyga) - Use NOC code J1599 - Covered for Primary humoral immunodeficiency (PI) in patients 2 years of age and older and Chronic immune thrombocytopenia.   500 mg $79.528 $75.552 Added October 2019
CMS priced January 2020
** Indeomethacin Sodium Trihydrate (Indocin) - Medicare does not pay for this service.         Added January 2020
** Indocin (see Indeomethacin Sodium Trihydrate)          
** Insulin Glargine (Toujeo, Lantus) - Considered Self-Administered.         Added January 2020
Integra Meshed Bilayer Wound Matrix   1 SQ cm $55.731 $52.944  
Invega Trinza (see Paliperidone Palmitaite)          
** Ipratropium Bromide - bill under J7644 or J3490. - If physician is providing instruction: Considered Self-Administered. If used during breathing treatment: Part of Procedure.         Added January 2020
** Isatuximab-irfc (Sarclisa) - [ICD-10 codes: C90.00, C90.02, C90.10, C90.12, C90.20, C90.22, C90.30, C90.32, Z85.79]   100 mg $689.000 $654.550 Added March 2020
** Isopropyl Alcohol/Peginterferon Alfa-2A (see Peginterferon Alfa-2A/Isopropyl Alcohol)          
Isoproterenol Hydrochloride (Isuprel)    0.2 mg $2.250 $2.138  
Isoptin IV (see Verapamil Hydrochloride)          
Isuprel (see Isoproterenol Hydrochloride)          
** Ixekizumab (Taltz) - Considered Self-Administered.         Added January 2020
Ixinity (see Coagulation Factor IX, Recombinant)          
** Joint Tunnel and Trigger Kit - Considered Part of Procedure.          
** Juvederm - all formulations (see Restylane)         Added September 2018
** K-Lyte - Considered Self-Administered.         Added January 2020
** Kayexilate (oral) - Considered Self-Administered.         Added January 2020
Kedrab (see Rabies Immune Globulin)          
** 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
** Kevzara (see Sarilumab)          
** Kineret (see Anakinra)          
**Kynamro (see Mipomersen Sodium)          
Labetalol Hcl (Trandate, Normodyne) [ICD-10: I10, I11.0, I11.9, I12.0, I12.9, I13.0, I13.2, I13.10-I13.11, I15.0-I15.2, I15.8-I15.9, N26.2]   5 mg $0.223 $0.212 Updated January 2020
** Lantus (see Insulin Glargine)          
** 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
** Liraglutide-GLP-1 agonist DM (Victoza, Saxenda) - Considered Self-Administered.         Added January 2020
Lopressor (see Metoprolol Tartrate)          
** Loratadine (Alavrt, Claritin, Dimetapp ND, Tavist ND) - Considered Self-Administered.         Added January 2020
Lusedra (see Fospropofol Disodium injection)          
** Luspatercept-aamt (Reblozyl) - [ICD-10 code: D56.1]   25 mg $3,647.647 $3,465.265 Added March 2020
** 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)          
Marcaine Hydrochloride (see Bupivacaine Hydrochloride)        
Marcaine Hydrochloride, Sterile (see Bupivacaine, Sterile)          
** Marlido Kit - Considered Part of Procedure.         Added January 2020
Mazicon (see Flumazenil)          
** Meth Challenge (Methacholine) - Considered Part of Procedure.         Added January 2020
** Methacholine Chloride (Provocholine) (inhalation solution) - Considered Part of Procdure.         Added January 2020
** Methohexilate (Brevital) Anesthesia - Considered Part of Procedure.         Added January 2020
** Methotrexate - Solution Auto-injector Non-chemotherapeutic (Otrexup, Rasuvo) - Considered Self-Administered.         Added January 2020
** Methylene Blue (Provayblue) - Considered Part of Procedure.         Added February 2020
Methylnaltrexone Bromide (Relistor) - Considered Self-Administered.          
Metoprolol Tartrate (Lopressor) - Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.   1 mg $0.209 $0.199  
** Metreleptin (Myalept) - Considered Self-Administered.         Added January 2020
Metronidazole In Nacl. inj (Flagyl IV) - When Administered in physician's office: [ICD-10: A00.0-A00.1, A00.9, A01.01-A01.05, A01.09, A02.0-A02.1, A02.20-A02.25, A02.29, A02.8-A02.9, A03.0-A03.3, A03.8-A03.9, A04.0-A04.9, A05.0-A05.5, A05.8-A05.9, A06.0-A06.7, A06.81-A06.82, A06.89, A06.9, A07.0-A07.4, A07.8-A07.9, A08.0, A08.11, A08.19, A08.2, A08.31-a08.32, A08.39, A08.4, A08.8, A09, A48.0, A48.1-A48.4, A48.51-A48.52, A48.8, A49.01-A49.02, A49.1-A49.3, A49.8-A49.9B95.0-B95.5, B95.61-B95.62, B95.7-B95.8, B96.1, B96.21-B96.23, B96.29, B96.0, B96.3-B96.7, B96.81-B96.82, B96.89, J13, J14, J15.0-J15.1, J15.20, J15.211-J15.212, J15.29, J15.3-J15.6, J15.8-J15.9, J18.1, J20.0- J20.2, K65.0-K65.4, K65.8-K65.9, K67, K68.12, K68.19, K68.9 K90.81, M00.111-M00.112, M00.121-M00.122, M00.131-M00.132, M00.141-M00.142, M00.151-M00.152, M00.161, M00.162, M00.171-M00.172, M00.18-M00.19, M60.009, N13.9, N36.0-N36.2, N36.41-N36.43, N36.5, N36.8-N36.9, N39.0, N39.8-N39.9, N71.0-N71.1, N71.9, R31.0-R31.2, R31.9]   500 mg $1.185 $1.126 Updated January 2020
Miconazole (Monistat IV) 10 mg     Invoice Invoice  
** Mipomersen Sodium (Kynamro) - Considered Self-Administered.         Added January 2020
Monistat IV (see Miconazole)          
Morrhuate Sodium   50 mg $2.105 $2.000  
** Myalept (see Metreleptin)          
** Mylicon Gas Drops 15cc - Medicare does not pay for this service.         Added January 2020
Nafcillin Sodium (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 - Medicare does not pay for this service.         Added August 2019
** Natpara (see Parathyroid Hormone)          
** Netilmicin Sulfate (Netromycin), 150 mg     Invoice Invoice  
** Neurolytic Solutions - Considered Part of Procedure.          
** Nexium IV (see Esomeprazole Sodium)          
** Nitro paste/ Nitro bid/ Nitro (per grain) - Medicare does not pay for this service.         Added January 2020
Nitroglycerin - Allowed in emergency situations.   5 mg $1.205 $1.145  
Norcuron (see Vecuronium Bromide)          
** Norepinephrine Bitartrate (Levophed Bitartrate) Allowed in emergency situations.   1 mg $4.775 $4.536 Updated August 2019
Normal Saline (Sterile Water)   5 cc/50 ml $1.430 $1.359  
Normodyne (see Labetalol Hydrochloride)          
** NTG (oral strip) - Medicare does not pay for this service.         Added January 2020
Ofloxacin (Floxin IV), 20 mg   No Source Available Invoice Invoice  
Olanzapine short acting intramuscular injection (Zyprexa IM) - Allowed when administered in physician's office: [ICD-10: F20.0-F20.2, F20.5, F20.81, F20.89, F25.0-F25.1, F25.8-F25.9]   0.5 mg $1.327 $1.261 Updated January 2020
Ontak (see Denileukin Difitox)          
** Optison   No Source Available Invoice Invoice  
** Orencia (see Abatacept)          
** Otrexup (see Methotrexate - Solution Auto-injector Non-chemotherapeutic)          
** Ovidrel (see Chorionic Gonadotropin Alfa, Recombinant)          
** Ozempic (see Semaglutide)          
** Padcev (see Enfortumab Vedotin-ejfv)          
Paliperidone Palmitate (Invega Trinza)   1 mg $9.744 $9.257  
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 (see Immune Globulin)          
** Parathyroid Hormone (Natpara) - Considered Self-Administered.         Added January 2020
** Pasireotide Diaspartate (Signifor) - Considered Self-Administered.         Added January 2020
** Pegasys (see Peginterferon Alfa-2A)          
Pegfilgrastim-bmez (Ziextenzo)   0.5 mg $336.941 $320.094 Added January 2020
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) - Considered Self- Administered.          
** Peginterferon Alfa-2B, 150mcg (Pegintron, Sylatron) - Considered Self-Administered.          
** Peginterferon Beta-1A (Plegridy) - Considered Self-Administered.         Added January 2020
** Pegintron (see Peginterferon Alfa-2B)          
** Pegvisomant (Somavert) Considered Self-Administered.          
** Pentothal - Considered Part of Procedure.         Added January 2020
Pepcid (see Famotidine)          
** Perlane (see Restylane)         Added September 2018
** Phenol - Medicare does not pay for this service.         Added January 2020
** 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
** Plegridy (see Peginterferon Beta-1A)          
** 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]   1 mg $113.383 $107.714 Added August 2019 /
Eff. 01/01/2020 use code J9309
Polidocanol (see Asclera)          
** Polidocanol Foam (see Varithena)          
** Polivy (see Polatuzumab Vedotin/Polatuzumab Vedotin-piiq)          
** Polyestradiol Phosphate (Estradurin) - Not FDA Approved - Medicare does not pay for this service.         Added January 2020
Potassium Acetate   2 meq $0.027 $0.026  
Potassium Phosphate   3 mmol $0.043 $0.041  
** Praluent (see Alirocumib)          
** Pramlintide Acetate (Symlinpen) - Considered Self-Administered.         Added January 2020
Procaine Hydrochloride   1% $2.360 $2.242  
Procaine Hydrochloride   2% $3.400 $3.230  
** Procardia - Considered Self-Administered.         Added January 2020
** 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)          
** Provayblue (see Methylene Blue)          
** Provocholine (see Methacholine Chloride)          
** Quad-Mix (see Alprostadil/Papaverine/Phentolamine/Atropine)          
** R-Gene 10 (see Arginine Hcl.)          
Rabies Immune Globulin (Kedrab)   150 IU $317.481 $301.607 Added January 2020
** Rasuvo (see Methotrexate - Solution Auto-injector Non-chemotherapeutic)          
**Reblozyl (see Luspatercept-aamt)          
Relistor (see Methylnaltrexone Bromide)          
Renu Voice (RENU') ICD-10 J38.00-J38.02 , J38.3     Invoice Invoice Added May 2016
** Repatha and Repatha Sureclick (see Evolocumab)        
** 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 $96.572 $91.743  
** Risankizumab-rzaa (Skyrizi) - ICD-10 codes: [L40.1, L40.2, L40.3, L40.4, L40.8, L40.9]   1 mg $111.947 $106.350 Added January 2020
Rituximab-pvvr (Ruxience) - ICD-10 codes: [B20; C79.32; C79.49; C81.00; C81.01; C81.02; C81.03; C81.04; C81.05; C81.06; C81.07; C81.08; C81.09; C81.11; C81.12; C81.13; C81.14; C81.15; C81.16; C81.17; C81.18; C81.19; C81.21; C81.22; C81.23; C81.24; C81.25; C81.26; C81.27; C81.28; C81.29; C81.31; C81.32; C81.33; C81.34; C81.35; C81.36; C81.37; C81.38; C81.39; C81.41; C81.42; C81.43; C81.44; C81.45; C81.46; C81.47; C81.48; C81.49; C81.71; C81.72; C81.73; C81.74; C81.75; C81.76; C81.77; C81.78; C81.79; C81.91; C81.92; C81.93; C81.94; C81.95; C81.96; C81.97; C81.98; C81.99; 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; C82.58; 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; C83.03; 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; C83.50; C83.51; C83.52; C83.53; C83.54; C83.55; C83.56; C83.57; C83.58; C83.59; 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; C84.41; C84.42; C84.43; C84.44; C84.45; C84.46; C84.47; C84.48; C84.49; C84.61; C84.62; C84.63; C84.64; C84.65; C84.66; C84.67; C84.68; C84.69; C84.71; C84.72; C84.73; C84.74; C84.75; C84.76; C84.77; C84.78; C84.79; C84.91; C84.92; C84.93; C84.94; C84.95; C84.96; C84.97; C84.98; C84.99; C84.A1; C84.A2; C84.A3; C84.A4; C84.A5; C84.A6; C84.A7; C84.A8; C84.A9; C84.Z1; C84.Z2; C84.Z3; C84.Z4; C84.Z5; C84.Z6; C84.Z7; C84.Z8; C84.Z9; C85.10; C85.11; C85.12; C85.13; C85.14; C85.15; C85.16; C85.17; C85.18; C85.19; 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; C85.91; C85.92; C85.93; C85.94; C85.95; C85.96; C85.97; C85.98; C85.99; C86.0; C86.1; C86.2; C86.3; C86.4; C86.5; C86.6; C88.0; C88.4; C91.00; C91.01; C91.02; C91.10; C91.11; C91.12; C91.40; C91.41; C91.42; C96.4; C96.9; C96.Z; D36.0; D44.6; D44.7; D47.Z1; D47.Z2; D59.0; D59.1; D68.311; D68.312; D68.318; D69.3; D69.41; D69.42; D69.49; G04.81; L10.0; M05.011; M05.012; M05.021; M05.022; M05.031; M05.032; M05.041; M05.042; M05.051; M05.052; M05.061; M05.062; M05.071; M05.072; M05.09; M05.211; M05.212; M05.221; M05.222; M05.231; M05.232; M05.241; M05.242; M05.251; M05.252; M05.261; M05.262; M05.271; M05.272; M05.29; M05.311; M05.312; M05.321; M05.322; M05.331; M05.332; M05.341; M05.342; M05.351; M05.352; M05.361; M05.362; M05.371; M05.372; M05.39; M05.411; M05.412; M05.421; M05.422; M05.431; M05.432; M05.441; M05.442; M05.451; M05.452; M05.461; M05.462; M05.471; M05.472; M05.49; M05.511; M05.512; M05.521; M05.522; M05.531; M05.532; M05.541; M05.542; M05.551; M05.552; M05.561; M05.562; M05.571; M05.572; M05.59; M05.611; M05.612; M05.621; M05.622; M05.631; M05.632; M05.641; M05.642; M05.651; M05.652; M05.661; M05.662; M05.671; M05.672; M05.69; M05.711; M05.712; M05.721; M05.722; M05.741; M05.742; M05.751; M05.752; M05.761; M05.762; M05.771; M05.772; M05.79; M05.811; M05.812; M05.821; M05.822; M05.831; M05.832; M05.841; M05.842; M05.851; M05.852; M05.861; M05.862; M05.871; M05.872; M05.89; M06.011; M06.012; M06.021; M06.022; M06.031; M06.032; M06.041; M06.042; M06.051; M06.052; M06.061; M06.062; M06.071; M06.072; M06.08; M06.09; M06.1; M06.211; M06.212; M06.221; M06.222; M06.231; M06.232; M06.241; M06.242; M06.251; M06.252; M06.261; M06.262; M06.271; M06.272; M06.28; M06.29; M06.311; M06.312; M06.321; M06.322; M06.331; M06.332; M06.341; M06.342; M06.351; M06.352; M06.361; M06.362; M06.371; M06.372; M06.38; M06.39; M06.811; M06.812; M06.821; M06.822; M06.831; M06.832; M06.841; M06.842; M06.851; M06.852; M06.861; M06.862; M06.871; M06.872; M06.88; M06.89; M30.0; M30.1; M30.2; M30.8; M31.1; M31.30; M31.31; M31.7; N18.6; R59.0; R59.1; R59.9; T86.01; T86.02; T86.03; T86.09; T86.11; T86.12; T86.13; T86.19; T86.5; Z85.71; Z85.72; Z85.79]   10 mg $73.830 $72.182 Added January 2020 / Eff. 1/23/2020
/ CMS priced April 2020
Robinul (see Glycopyrrolate)          
Romazicon (see Flumazenil)          
Ruxience (see Rituximab-pvvr)          
** Sarapin (see Sarracenia Purprua)          
** Sarclisa (see Isatuximab-irfc)          
** Sarilumab (Kevzara) - Considered Self-Administered.         Added January 2020
** Sarracenia Purpura (Sarapin) - Medicare does not pay for this service.          
** Saxenda (see Liraglutide-GLP-1 agonist DM)          
** Secukinumab (Cosentyx) - Considered Self-Administered.         Added January 2020
** Semaglutide (Ozempic) - Considered Self-Administered.         Added January 2020
** Sensorcaine-MPF/EPINEPHrine; Sensorcaine/EPINEPHrine (see Bupivacaine Hydrochloride & Epinephrine Bitartrate)          
Sensorcaine (see Bupivacaine Hydrochloride)          
Sensorcaine, Sterile (see Bupivicaine, Sterile)          
** Signifor (see Pasireotide Diaspartate)          
** Siliq (see Brodalumab)          
** Silvadene - Medicare does not pay for this service.         Added January 2020
** Silver Nitrate - Medicare does not pay for this service.         Added January 2020
** Simponi Non-IV form (see Golimumab Non-IV form)          
** Skyrizi (see Risankizumab-rzaa)          
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 0.9% IV - Considered Part of Procedure.         Added January 2020
Sodium Chloride, Hypertonic (3%-5% infusion)   250 cc $1.392 $1.322  
** Sodium Hyaluronate/Chondroitin Sulfate (Viscoat) - Considered Part of Procedure.         Added January 2020
** 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)   5 cc $0.052 $0.049  
** Sotradecol (see Sodium Tetradecyl Sulfate)          
** Staphagelysate (SPL) - Medicare does not pay for this service.         Added January 2020
Stavzor - Considered Self-Administered.          
Sterile Saline / Water   1000 ml $5.640 $5.358  
** Strensiq (see Asfotase-alfa)          
** Sulfacetamide (ointment) - Medicare does not pay for this service.         Added January 2020
Sulfamethoxazole/Trimethoprim (SMZ/TMP)   400-80mg $0.570 $0.542  
SurgiMend   0.5 sq cm $12.426 $11.805  
Sylatron (see Peginterferon Alfa-2B)          
** Symlinpen (see Pramlintide Acetate)          
Tagamet (see Cimetidine Hydrochloride)          
** Taltz (see Ixekizumab)          
** Tanzeum (see Albiglutide)          
** Tenormin (see Atenolol)          
Tensilon (see Edrophonium Chloride)          
** Tepezza (see Teprotumumab-trbw)          
** Teprotumumab-trbw (Tepezza) [ICD-10: E05.00]   10 mg $315.880 $300.086 Eff. 1/28/2020; Added May 2020
** Tesamorelin (Egrifta) - Considered Self-Administered.         Added January 2020
Testosterone   1 mg $0.110 $0.105  
** Testosterone Pellets (Testopel) - Use J3490 for the pellets and 11980 for the administration of the pellets. [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)        
** Tetrabenazine - Medicare does not pay for this service.         Added January 2020
** Thalidomide (Thalomid) - Should be billed as J8999cc. Must be billed to DMAC.         Added January 2020
** Thiamine - Medicare does not pay for this service.         Added January 2020
** Thrombin (Recothrom) - Considered Part of Procedure. If billed alone - Medicare does not pay for this service.         Added January 2020
Timentin (see Clavulanate Potassium/Ticarcillin Disodium)          
** Toujeo (see Insulin Glargine)          
** Trace Minerals (Multitrace-5) - Non-covered by carrier         Added May 2019
** Tramadol (ConZip, Rybix ODT, Ultram) - Considered Self-Administered.         Added January 2020
Trandate (see Labetalol Hydrochloride)          
** Traumeel - Medicare does not pay for this service.         Added January 2020
**Tri-Mix (see Alprostadil/Papaverine/Phentolamine)          
** Trulicity (see Dulaglutide)          
** Tuberculin PPD - when used as an intralesional injection to treat a condition, it's considered investigational.         Added December 2019
** Tylenol - Considered Part of Procedure.         Added January 2020
** Tymlos (see Abaloparatide)          
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- Considered Self-Administered.          
** Varithena (Polidocanol foam) ICD-10s I83.001-I83.899   1 mg $7.526 $7.150 Added March 2015
Vasopressin   20 units $176.153 $167.345  
Vasotec IV (see Enalaprilat)          
Vecuronium Bromide (Norcuron)   1 mg $0.223 $0.212  
Verapamil Hydrochloride (Isoptin IV)   2.5 mg $7.714 $7.328  
** Victoza (See Liraglutide-GLP-1 agonist DM)          
** Viscoat (see Sodium Hyaluronate/Chondroitin Sulfate)          
** Vitamin (multi) - Medicare does not pay for this service.         Added January 2020
** Vitamin B Complex 100   1 ml $6.505 $6.180 Updated October 2019
** Vitamin C (see Ascorbic Acid) (Cenolate) - Medicare does not pay for this service.          
** Vitamin D injections - Medicare does not pay for this service.         Added August 2019
** 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
** Vyepti (see Eptinezumab-jjmr)          
** Xopenex - Medicare does not pay for this service.         Added January 2020
Ziextenzo (see Pegfilgrastim-bmez)          
Zyprexa IM (see Olanzapine)          

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved