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2023 2nd Quarter Payment Allowance Limits for Not Otherwise Classified (NOC) Drugs

Revised: 07.17.23

Effective April 1, 2023 through June 30, 2023

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.

Code C9399 - for Part B, must be in an ASC place of service

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 2Q23 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
** Abaloparatide (Tymlos) - Considered Self-Administered.         Added January 2020
** Abatacept (Orencia) - Considered Self-Administered.         Added January 2020 / Use code J0129 for IV infusion only
** Abecma (see Idecabtagene Vicleucel)          
** ABX-GEF drug study - Medicare does not cover this service.          
** Actiq (see Fentanyl Citrate)          
** 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
** Adbry ( see Tralokinumab-ldrm)          
** Aducanumab-avwa-(Aduhelm) - Medical documentation for coverage consideration.   100mg/ml $593.600 $563.920 Added October 2021
**Aduhelm-(Aducanumab-avwa)          
** 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 $2.162 $2.054 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** 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 $2,889.811 $2,745.320 Updated January 2020 / Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** 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 $0.329 $0.313 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Amjevita (see Adalimumab-atto)          
** Amvuttra (Vutrisiran)          
** Anakinra (Kineret) - Considered Self-Administered.         Added January 2020
** Anifrolumab-fnia (Saphnelo) Covered for the treatment of Systemic lupus erythematosus, moderate to severe [M32.10; M32.11; M32.12; M32.13: M32.14; M32.15; M32.19; M32.8; M32.9]   2 ml $4,876.572 $4,632.743 Added December 2021 / CMS priced April 2022
** Arginine Hydrochloride (R-Gene 10)   300 ml/30 grams $40.651 $38.618 Updated October 2016 / Updated August 2019 / Updated April 2020
** Argyrol - Considered Part of Procedure.         Added January 2020
Asceniv (see Immune Globulin)          
** 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)          
Avastin (See Bevacizumab)          
Aztreonam (Azactam)   500 mg $14.801 $14.061 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Bacitracin (Baciim)   50,000 U $6.890 $6.546 Updated April 2020
** Becicizmn   No Source Available Invoice Invoice Added January 2020
** Belantamab mafodotin-blmf (Blenrep) Indicated for the treatment of adult patients with relapsed or refractory multiple myeloma who have received at least 4 prior therapies including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent [ICD-10: C90.00; C90.02; C90.10; C90.12; C90.20; C90.22; C90.30; C90.32]   100 mg $8,773.620 $8,334.939 Eff. 8/21/2020 - Added September 2020
** Benzylpenicilloyl polylysine (PRE-PEN)   0.25 ml $157.516 $149.640 Added October 2021
** Besremi (see Ropeginterferon alfa-2b-njft)          
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-10's 05/15/2017 Added new ICD-10's 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
** Bimatropost (Durysta) Implant, Intraocular - [ICD-10: H40.1111; H40.1112; H40.1113; H40.1114; H40.1121; H40.1122; H40.1123; H40.1124; H40.1131; H40.1132; H40.1133; H40.1134; H40.051; H40.052; H40.053]   1 mcg $206.700 $206.700 Added July 2020 / Updated October 2020. Eff. 10/01/2020 - Use code J7351.
** Bimatropost Solutions (Latisse, Lumigan, Vistitan) - Considered Self-Administered.         Added July 2020
** Blenrep (see Belantamab mafodotin-blmf)          
** Blind Drug Study - Considered Investigational         Added May 2019
** BMS Study Drug - Medicare does not pay for this service.         Added January 2020
Bortezomib (Dr. Reddy's)   0.1 MG $17.974 $17.075 CMS added July 2022 / Updated October 2022
** Bretylium Tosylate (Bretylol)   5 mg $2.639 $2.507 Updated April 2020
Brevibloc (see Esmolol Hydrochloride)          
** Brevital (see Methohexilate)          
** Breyanzi (see lisocabtagene maraleucel)          
** Brodalumab (Siliq) - Considered Self-Administered.         Added January 2020
** Brompton's Cocktail - Considered Self-Administered.         Added January 2020
Bumetanide (Bumex)   0.25 mg $0.350 $0.333 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
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 $0.123 $0.117 Updated January 2020 / Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
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
**Bupivacaine & Meloxicam (Zynrelef) - C9399, J3490, or J3590 – Not payable separately / Considered part of the procedure being performed.         Added October 2021
** Buscopan (see Hyoscine or Scopolamine)          
** Bydureon (see Exenatide XR)          
** Byetta (see Exenatide)          
**Cabotegravir/Rilpivirine (Cabenuva) [B20 or Z21]   1ml $1,049.400 $996.930 Added April 2021 - Eff. 1/22/2021
Cabenuva (See Cabotegravir/Rilpivirine)          
Calciferol (see Ergocalciferol D2)          
** Calcium Chloride   100 mg / ml $1.478 $1.404 Updated April 2020 / Updated October 2020
** Candida Albicans   Invoice     Updated October 2019
Candida Antigen - Considered Part of Procedure.          
Cardizem IV (see Diltiazem Hydrochloride)          
** Cefotetan Disodium   1 gm $20.384 $19.365 Updated April 2020
** 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)   Invoice Updated April 2020
** Cineraria eye drops - physician's office: Considered Part of Procedure, taken home: Considered Self-Administered.         Added January 2020
** Clavulanate Potassium / Ticarcillin Disodium (Timentin)   Invoice Updated April 2020
** Clevidipine Butyrate (Cleviprex)   Invoice Updated April 2020
Clindamycin Phosphate (Cleocin)   150 mg $1.018 $0.967 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Clorafed - Medicare does not pay for this service.         Added January 2020
Coagulation Factor IX, Recombinant (Ixinity)   1 IU $1.826 $1.735 Includes clotting factor furnishing fee / Updated April 2021 / Updated July 2022 / Updated October 2022
** Colyte Flavored - Medicare does not pay for this service.         Added January 2020
** Copper Chloride - [ICD-10: E61.0]   0.4 mg $0.774 $0.735 Added April 2020
** Copper Sulfate   Invoice Updated April 2020
** Cosela (see Trilaciclib)          
** Cosentyx (see Secukinumab)        
** 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 $74.200 $70.490 Updated April 2020
** Daratumumab/Hyaluronidase-ifhj (Darzalex Faspro) - [ICD-10s: C90.00; C90.02; C90.10; C90.12; C90.20; C90.22; C90.30; C90.32; Z85.79]   1800 mg/15 ml-30000 u/15 ml; 15ml vial $8,028.440 $7,627.018 Added July 2020
** Darzalex Faspro (see Daratumumab/Hyaluronidase-ifhj)          
** 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)   Invoice Updated April 2020
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 / Updated October 2020
** Diatrizoate Meglumine (Cystografin)   10 ml $1.144 $1.087 Updated April 2020
Diltiazem Hydrochloride (Cardizem IV)   5 mg 0.307 $0.292 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
Divalproex Sodium - Considered Self-Administered.          
Divalproex Sodium ER - Considered Self-Administered.          
** Dostarlimab-gxly (Jemperli) - Indicated for the treatment of adult patients with mismatch repair deficient (dMMR) recurrent or advanced endometrial cancer [C54.0; C54.1; C54.2; C54.3; C54.8; C54.9; C55]   10 ml $1,099.154 $1,044.196 Added May 2021 - Eff. 05/03/2021
** Doxapram Hydrochloride (Dopram)   20 mg $2.566 $2.438 Updated April 2020
Doxycycline Hyclate   100 mg $17.103 $16.248 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Dulaglutide (Trulicity) - Considered Self-Administered.         Added January 2020
** Dupilumab (Dupixent) Consider Self-Administered.          
** Dupixent (see Dupilumab)          
** Durysta (see Bimatropost)         Added July 2020
Edecrin Sodium (see Ethacrynate Sodium)          
** Edrophonium Chloride (Enlon) [ICD-10: G70.00-G70.01]   10 mg $5.653 $5.370 Updated April 2020
** Efgartigimod alfa-fcab (See Vyvgart) [ICD-10 G700.00-G70.01]   Invoice     Added March 2022
** Egrifta (see Tesamorelin)          
** Elahere (Mirvetuximab Soravtansine-gynx)          
** Elmiron - Considered Self-Administered.         Added January 2020
** Emgality (see Galcanezumab-gnlm)          
** Enalaprilat   1.25 mg $1.988 $1.889 Updated April 2020
** Enjaymo (Sutimlimab-jome)          
** 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 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]   Invoice Updated April 2020
Esmolol Hydrochloride (Brevibloc) - physician's office: [ICD-10: I49.8, R00.1]; during surgery: Considered Part of Procedure.   10 mg $0.299 $0.284 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** 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 $18.391 $17.471 Updated April 2020 / Updated October 2020
** Estradiol (Estrogen)   Invoice Updated April 2020
** 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)   Invoice Updated April 2020
** Ethyl Chloride Topical Anesthetic - Considered Part of Procedure.         Added January 2020
** Etomidate (Amidate)   2 mg $0.339 $0.322 Updated April 2020
** 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
Famotidine (Pepcid)   10 mg $0.346 $0.329 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Faricimab-svoa (see Vabysmo) - [ICD-10 Codes: E08.311, E08.321, E08.3211, E08.3212, E08.3213, E08.331, E08.3311, E08.3312, E08.3213, E08.341, E08.3411, E08.3412, E08.3413, E09.331, E09.3311, E09.3312, E09.3313, E09.341, E09.3411, E09.3412, E09.3413, E09.352,
E09.3521, E09.3522, E09.3223, E09.351, E09.3511, E09.3512, E09.3513, E10.311, E10.3211,
E10.3212, E10.3213, E10.3311, E10.3312, E10.3313, E10.3411, E10.3412, E10.3413, E10.3511,
E10.3512, E10.3513, E11.3211, E11.3212, E11.3213, E11.3311, E11.3312, E11.3313, E11.3411,
E11.3412, E11.3413, E11.3511, E11.3512, E11.3513, E13.311, E13.3211, E13. 3212, E13.3213,
E13.3291, E13.3311, E13.3312, E13.3313, E13.3411, E13.3412, E13.3413, E13.3511, E13.3512,
E13.3513, H35.321, H35.3211, H35.3212, H35.3213, H35.322, H35.3221, H35.3222, H35.3223,
H35.323, H35.3231, H35.3232, H35.3233.		   6mg $2,321.400 $2,205.330 Added April 2022
** Fentanyl Citrate (Actiq) Lozenge on a stick - Considered Self-Administered.         Added January 2020
** Ferric derisomaltose (Monoferric)   10 mg $26.121 $24.815 Added January 2021 - Eff. 9/25/2020
Firazyr (see Icantibant)          
Flagyl IV (see Metronidazole In Nacl.)          
Floxin IV (see Ofloxacin)          
Flumazenil (Mazicon, Romazicon)   0.1 mg $0.938 $0.891 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updatted October 2022
Folic Acid   5 mg $3.289 $3.125 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Folvite - Medicare does not pay for this service.         Added January 2020
** Fospropofol Disodium injection (Lusedra)   Invoice Updated April 2020
** Galcanezumab-gnlm (Emgality) - Considered Self-Administered.         Added January 2020
** GI Cocktail - Considered Part of Procedure.         Added January 2020
Glucarpidase (Voraxaze)   10 units $362.572 $344.443 Updated April 2021 / Updated July 2021
** 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 $1.982 $1.883 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** 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., (Hespan) 6 gm/500 ml   6 gm/500 ml $15.911 $15.115 Updated April 2020
** Hydroxocobalamin - Covered when billed with J9305.   1000 mcg/ml $0.883 $0.839 Updated April 2020
** 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.          
** Idecabtagene Vicleucel (Abecma) - Covered ICD-10s are [C90.00; C90.02] .   Should be billed to Part A     Added May 2021 / Eff. 3/29/2021 / Updated July 2021 / Updated August 2021
Immune Globulin (Asceniv)   500 mg $481.770 $457.682 Added April 2020
Immune Globulin (Cutaquig)   100 mg $12.768 $12.130 Added January 2020 / Updated April 2021 / Updated July 2021
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 $69.638 $66.156 Added October 2019
CMS priced January 2020 / Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
Immune Globulin (Xemblify)   100 mg $17.613 $16.732 Added April 2020
** Inclisiran (Leqvio) - is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (ASCVD), who require additional lowering of low-density lipoprotein cholesterol (LDL-C) [ICD-10s E78.01; I25.10; I25.110; I25.111; I25.118; I25.119; I25.2; I25.3; I25.41; I25.42; I25.5; I25.6; I25.700; I25.701; I25.708; I25.709; I25.710; I25.711; I25.718; I25.719; I25.720; I25.721; I25.728; I25.729; I25.730; I25.731; I25.738; I25.739; I25.750; I25.751; I25.758; I25.759; I25.760; I25.761; I25.768; I25.769; I25.790; I25.791; I25.798; I25.799; I25.810; I25.811; I25.812; I25.82; I25.83; I25.84]   284 mg $3,445.000 $3,272.750 Added April 2022
** Indeomethacin Sodium Trihydrate (Indocin) - Medicare does not pay for this service.         Added January 2020
** Indocin (see Indeomethacin Sodium Trihydrate)          
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump)   50 Units $8.461 $8.038 Added October 2022
** Insulin Glargine (Toujeo, Lantus) - Considered Self-Administered.         Added January 2020
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump)   50 Units $15.871 $15.077 Added October 2022
** Integra Meshed Bilayer Wound Matrix   1 SQ cm Invoice Invoice Updated April 2020
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 $355.100 $337.345 Updated April 2020 / Updated October 2020
Isoptin IV (see Verapamil Hydrochloride)          
Isuprel (see Isoproterenol Hydrochloride)          
** Ixekizumab (Taltz) - Considered Self-Administered.         Added January 2020
Ixinity (see Coagulation Factor IX, Recombinant)          
Jelmyto (see Mitomycin instillation)          
** Jemperli - (see Dostarlimab-gxly)          
** 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)          
** Kesimpta Pen - Considered Self-Administered   Deny     Added February 2023
** 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 $0.149 $0.142 Updated February 2019 / Updated April 2020
** Kevzara (see Sarilumab)          
** Kimmtrak (see tebentafusp)          
** 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 $0.186 $0.177 Updated January 2020 / Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Lantus (see Insulin Glargine)          
** Leqvio (see Inclisiran)          
** 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
** Lisocabtagene Maraleucel (Breyanzi)   Should be billed to Part A     Added July 2021 / Updated August 2021 - Eff. 7/1/2021 use code C9076.
Lopressor (see Metoprolol Tartrate)          
** Loratadine (Alavrt, Claritin, Dimetapp ND, Tavist ND) - Considered Self-Administered.         Added January 2020
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]		   Invoice Updated April 2020
** Magnesium Chloride Injection   200 mg/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)          
** Margenza (see Margetuximab-cmkb)          
** Margetuximab-cmkb (Margenza) - Covered for the treatment of metastatic HER2-positive breast cancer (in combination with chemotherapy) in adults who have received 2 or more prior anti-HER2 regimens, at least 1 of which was for metastatic disease. [ICD-10 codes: 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]   25 mg/ 1 ml $220.162 $209.154 Added May 2021
** Marlido Kit - Considered Part of Procedure.         Added January 2020
Mazicon (see Flumazenil)          
** Meloxicam & Bupivacaine- (Zynrelef) C9399, J3490, or J3590 – Not payable separately / Considered part of the procedure being performed.         Added October 2021
** Melphanlan Flufenamide (Pepaxto) - Covered for the Treatment of relapsed or refractory multiple myeloma (in combination with dexamethasone) in adults who have received at least 4 prior lines of therapy and whose disease is refractory to at least one proteasome inhibitor, one immunomodulatory agent, and one CD38-directed monoclonal antibody. [ICD-10 codes: C90.00, C90.02, C90.10, C90.12, C90.20, C90.22, C90.30, C90.32, D47.2, Z85.79]   20 mg $10,070.000 $9,566.500 Added May 2021
** 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 $0.152 $0.144 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** 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 $1.401 $1.331 Updated January 2020 / Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
Miconazole (Monistat IV) 10 mg     Invoice Invoice  
** Mipomersen Sodium (Kynamro) - Considered Self-Administered.         Added January 2020
** Mirvetuximab soravtansine-gynx (Elahere) - indicated for the treatment of adult patients with folate receptor alpha positive, platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer, who have received one to three prior systemic treatment regimens (C48.1, C48.2, C48.8, C56.1, C56.2, C56.3, C57.01, C57.02, C57.11, C57.12, C57.21, C57.22, C57.3, C57.4, C57.7, or C57.8 plus Z85.43 to show history of malignant neoplasm of ovary)   5 mg $320.330 $304.314 Added June 2023 / Effective July 2023 CMS started pricing - Use code J9063.
** Mometasone Furoate Sinus Implant (Propel, Propel Mini, Propel Mini with SDS, Propel Contour) – Placed at time of surgery - PROPEL (ethmoid sinus) J32.2; PROPEL Mini (ethmoid or frontal sinus) J32.2 or J32.1; PROPEL Mini with SDS (ethmoid sinus) J32.2; PROPEL Contour S1091 (frontal or maxillary sinus) J32.1 or J32.0   Each $1,537.000 $1,460.150 Added January 2022
Monistat IV (see Miconazole)          
** Monjuvi (See Tafasitamab-cxix)          
** Monoferric (see Ferric Derisomaltose)          
** Morrhuate Sodium   Invoice Updated April 2020
** Mounjaro (Tirzepatide) Injectable pen for Diabetes mellitus, type 2, treatment. Deny - Considered self-administred drug.   Deny     Added October 2022
** 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 $12.010 $11.410 Updated April 2020
** Nalmefene Hydrochloride (Revex)   Invoice Updated April 2020
** Nasal Sprays - Medicare does not pay for this service.         Added August 2019
** Natpara (see Parathyroid Hormone)          
** Nebilizumab-cdon (Uplizna) Indicated for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in adults who are anti-aquaporin-4 (AQP4) antibody positive, ICD-10 G36.0   10mg $4,628.670 $4,397.237 Added January 2021 - Eff. 6/11/2020
** 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 $1.362 $1.294 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
**Nivolumab/relatlimab-rebw (Opdualag) ICD-10 Codes [C43.0, , C43.111, C43.112, C43.121, C43.122, C43.21-C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61-C43.62, C43.71-C43.72, C43.8,]   240mg-80mg $14,515.926 $13,790.130 Added May 2022 / Updated June 2022
Norcuron (see Vecuronium Bromide)          
** Norepinephrine Bitartrate (Levophed Bitartrate) Allowed in emergency situations.   1 mg $4.775 $4.536 Updated August 2019 / Updated October 2020
** Normal Saline (Sterile Water)   Invoice Updated April 2020
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 $1.042 $0.990 Updated January 2020 / Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
Ontak (see Denileukin Difitox)          
** Opdualag (Nivolumab/relatlimab-rebw)          
** 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)          
Paliperidone Palmitate (Invega Trinza)   1 mg $11.288 $10.724 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.   40 mg $5.300 $5.035 Updated April 2020 / Updated October 2020
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)          
** Pegcetacoplan (see Syfovre)   15 mg $2,255.700 $2,142.915 Added March 2023 / Eff 2/17/2023 / Updated May 2023
** 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
** Pepaxto (see Melphalan Flufenamide)          
Pepcid (see Famotidine)          
** Perlane (see Restylane)         Added September 2018
** Pertuzumab/Trastuzumab/Hyaluronidase; zzsf (Phesgo) Covered for patients with HER-2 positive, malignant neoplasm of breast [(C50.011; C50.012; C50.021: C50.022: C50.111: C50.112: C50.121: C50.122: C50.211; C50.212; C50.221; C50.222; C50.311; C50.312; C50.321; C50.322; C50.411; C50.412; C50.421; C50.422; C50.511; C50.512; C50.521; C50.522; C50.611; C50.612; C50.621; C50.622; C50.811; C50.812; C50.821; C50.822; Z85.3)] – 1ml -   1 ml $897.926 $853.030 Added November 2020 / Updated February 2021 - Use code J9316
** Phenol - Medicare does not pay for this service.         Added January 2020
** Phesgo (See Pertuzumab/Trastuzumab/Hyaluronidase; zzsf)          
** 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
**Plarify - Approved for prostate cancer.   Invoice     Added October 2021 - Use code A9597
** Plegridy (see Peginterferon Beta-1A)          
Polidocanol (see Asclera)          
** Polidocanol Foam (see Varithena)          
** Polyestradiol Phosphate (Estradurin) - Not FDA Approved - Medicare does not pay for this service.         Added January 2020
** Potassium Acetate   2 meq/ 1 ml $0.208 $0.198 Updated April 2020 / Updated October 2020
** Potassium Phosphate   3 mmol $2.119 $2.013 Updated April 2020 / Updated October 2020
** Praluent (see Alirocumib)          
** PRE-PEN (benzylpenicilloyl polylysine)          
** Pramlintide Acetate (Symlinpen) - Considered Self-Administered.         Added January 2020
** Procaine Hydrochloride   1% Invoice Updated April 2020
** Procaine Hydrochloride   2% Invoice Updated April 2020
** 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
**Propel (see Mometasone Furoate Implant (Propel, Propel Mini, Propel Mini with SDS, Propel Contour)          
Protonix IV (see Pantoprazole Sodium)          
** Provayblue (see Methylene Blue)          
** Provocholine (see Methacholine Chloride)          
** Quad-Mix (see Alprostadil/Papaverine/Phentolamine/Atropine)          
**Qutenza - Allow if billed with 64999. CPT code J7336 must also be on the claim and one of the following ICD-10 codes: [B02.23, B02.29, E10.40, E10.41, E10.42, E11.40, E11.41, E11.42].     Invoice Invoice Added November 2021
** R-Gene 10 (see Arginine Hcl.)          
Rabies Immune Globulin (Kedrab)   150 IU $243.784 $231.595 Added January 2020 / Updated April 2021 / Updated July 2021
** Ranibizumab-eqrn (Cimerli)   0.3 mg $840.480 $798.456 Added March 2023
** Ranibizumab-eqrn (Cimerli)   0.5 mg $1,400.800 $1,330.760 Added March 2023
** Ranibizumab (see Susvimo)   10mg $8,480.000 $8,056.000 Added April 2022
** Rasuvo (see Methotrexate - Solution Auto-injector Non-chemotherapeutic)          
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)          
** RIABNI (See Rituximab-arrx)          
** Riboflavin 5' - phosphate (see Photrexa Viscous or Photrexa Viscous-Photrexa Viscous Kit)      
Rifampin   600 mg $95.198 $90.438 Updated April 2021 / Updated July 2021 / Updatd July 2022 / Updated October 2022
** 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-arrx (RIABNI) [ICD-10: B10.89; B20; C82.00; C82.01; C80.02 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; C83.32; 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; C85.86; 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; C836.36; C83.37; C83.38; C83.39; C83.70-C83.79; C83.80-C83.89; C83.90; C83.91; C83.92; C83.93; C83.94; C83.95; C83.96; C83.97; C83.98; C83.99; 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; C85.86; C85.87; C85.88; C85.89; C88.4; C91.10; C91.12; C91.40; C91.42; D47.Z1]   10 mg $75.981 $72.182 Added February 2021
Robinul (see Glycopyrrolate)          
Romazicon (see Flumazenil)          
** Ropeginterferon alfa-2b-njft (see Besremi) - Considered Self-Administered.         Added March 2022
** Sacituzumab Govitecan-hziy (Trodelvy) [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, Z85.3]   180 mg $2,133.250 $2,026.588 Added June 2020
** Saphnelo (see Anifrolumab-fnia)          
** 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 $0.067 $0.064 Updated April 2020
** Sodium Bicarbonate, 4.2% (NaHC03)   1 ml $1.146 $1.089 Updated August 2019 / Updated October 2020
** Sodium Bicarbonate, 7.5% (NaHC03)   50 ml $15.508 $14.733 Updated August 2019 / Updated October 2020
** Sodium Bicarbonate, 8.4% (NaHC03)   50 ml $12.752 $12.114 Updated April 2020 / Updated October 2020
** Sodium Chloride 0.9% IV - Considered Part of Procedure.         Added January 2020
Sodium Chloride, Hypertonic (3%-5% infusion)   250 cc $1.373 $1.304 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** 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   Invoice Updated April 2020
** Sogroya (See Somapacitan-beco)          
** Somapacitan-beco (Sogroya) - Considered Self-Administered.         Added February 2021 - Eff. 03/27/2021
** 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 $0.669 $0.636 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
** SurgiMend   Invoice Updated April 2020
** Susvimo (see Ranibizumab)          
** Sutimlimab-jome (See Enjaymo)   50 mg $86.727 $82.391 Added August 2022 / Eff 10/01/2022 use code J1302
** Syfovre (see Pegcetacoplan)          
Sylatron (see Peginterferon Alfa-2B)          
** Symlinpen (see Pramlintide Acetate)          
** Tafasitamab-cxix (Monjuvi) - Indicated in combination with lenalidomide for adult patients for the following diagnoses: [C83.31; C83.32; C83.33; C83.34; C83.35; C83.36; C83.37; C83.38; C83.39; C85.21; C85.22; C85.23; C85.24; C85.25; C85.26]   200 mg $1,272.000 $1,208.400 Eff: 8/3/2020 - Added September 2020 / Updated November 2020
Tagamet (see Cimetidine Hydrochloride)          
** Taltz (see Ixekizumab)          
** Tanzeum (see Albiglutide)          
** Tebentafusp (see Kimmtrak)   100 mcg $19,885.600 $18,891.320 Added February 2022 / Effective 1/26/2022 / Updated May 2022
** Tegaderm (Wound Management) - Not payable separately / Considered part of the procedure being performed.   Deny     Added February 2023
** Tenormin (see Atenolol)          
Tensilon (see Edrophonium Chloride)          
Tepezza (see Teprotumumab-trbw)  
Teprotumumab-trbw (Tepezza) - [ICD-10: E05.00]   10 mg $315.880 $300.086 Added April 2020 / Eff. 10/1/2020 - use code J3241
** Tesamorelin (Egrifta) - Considered Self-Administered.         Added January 2020
** Testosterone (Androderm)   1 mg $0.544 $0.517 Updated April 2020
** 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 $111.442 $105.870 Updated with ICD-10. Pricing info Eff: October 2016 Eff:7/3/2018 - updated October 2018 / Updated April 2020
Tetanus Toxoid (use codes 90702, 90703, or 90718)        
** Tetrabenazine - Medicare does not pay for this service.         Added January 2020
** Tezepelumab-ekko (Tezspire) - Used as an add-on maintenance treatment for severe Asthma [J45.50 or J45.51]   10 mcg $3,850.980 $3,658.431 Added April 2022
** (Tezspire) (see Tezepelumab-ekko)          
** 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) Trace Elements - Non-covered by carrier         Added May 2019
** Tralokinumab-ldrm (Adbry)   150mg $887.432 $843.060 Added September 2022
** 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
** Triamcinolone acetonide (XIPERE)   0.9ml $1,749.000 $1,661.550 Added January 2022
** Trilaciclib (Cosela) - Indication to decrease the incidence of chemotherapy-induced myelosuppression when administered prior to a platinum/etoposide-containing regimen or topotecan-containing regimen for extensive-stage small cell lung cancer (ES-SCLC) in adults [D61.810; D61.811; D64.81; D70.1; T45.1X5A; T45.1X5D; T45.1X5S; Z51.11]– 50 mg   50mg $250.337 $237.820 Added May 2021 / Updated June 2021
**Tri-Mix (see Alprostadil/Papaverine/Phentolamine)          
** Trodelvy (see Sacituzumab Govitecan-hziy)          
** 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)          
** Uplizna (see nebilizumab-cdon)          
** Vabysmo (see Faricimab-svoa)          
** Valproate Sodium 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, 40.909, G40.911, G40.919, G40.A01, G40.A09, G40.A11, G40.A19, G40.B01, G40.B09, G40.B11, G40.B19)]   100 mg $0.763 $0.725 Updated April 2020 / Updated October 2020
Valproic Acid- Considered Self-Administered.          
** Varithena (Polidocanol foam)  ICD-10's I83.001-I83.899   1 mg $7.526 $7.150 Added March 2015
Vasopressin   20 units $172.139 $163.532 Updated April 2021 / Updated July 2021 / Updated July 2022 / Updated October 2022
Vasopressin (American Regent)   20 units $136.351 $129.533 Added October 2022
Vasotec IV (see Enalaprilat)          
** Vecuronium Bromide   1 mg $0.551 $0.523 Updated April 2020 / Updated October 2020
** Verapamil Hydrochloride   2.5 mg $8.439 $8.017 Updated April 2020 / Updated October 2020
** 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
** Vutrisiran (Amvuttra) Indicated for treatment of polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults – E85.1   Each $122,827.500 $116,686.125 Added November 2022
** Vyepti (see Eptinezumab-jjmr)          
**Vyvgart (see efgartigimod alfa-fcab)          
Xemblify (see Immune Globulin)          
**Xipere (see triamcinolone acetonide)          
** Xopenex - Medicare does not pay for this service.         Added January 2020
** Zynrelef (Bupivacaine & Meloxicam)          
Zyprexa IM (see Olanzapine)          

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