Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective April 1, 2022 through June 30, 2022
Revised: 12.08.22
Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html
Note 2: Payment allowance limits subject to the ASP methodology are based on 1Q21 ASP data.
Note 3: 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.
Note 4: Skin substitutes/wound care base products are not injectable drugs and therefore, do not fall under the same guidelines for pricing. Invoice information will be required with claim submitted if not CMS priced.
Note 5: ** – Carrier-priced
HCPCS Code | Short Description | HCPCS Code Dosage | Payment Limit | Notes |
---|---|---|---|---|
90396** | varicella-zoster immune globulin | 125 U / 1.25 ML | Invoice | |
90396** | varicella-zoster immune globulin | 625 U / 6.25 ML | Invoice | |
90630 | IIV4 Vacc no prsv 3 yrs+id | 0.1 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
90654 | Flu vaccine, intradermal, no preserv | Non FDA Approved | No new pricing available for the 2021-2022 flu season. | |
90655 | Flu vaccine no preserv 6-35m, im | 0.25 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
90657 | Flu vaccine, 6-35 mo, im | 0.25 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
90661 | Flu vaccine, derived from cell cultures, subunit | 45 MCG/0.5 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
90666 | Influenza virus vaccine | Per Carrier Medical Director not covered by Part B. | ||
90673 | Flublok, trivalent 18 & > | 0.5 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
90689 | Vacc iiv4 no prsrv | Non FDA Approved | ||
90736** | Zostavax (live/attenuated form ) | Per Carrier Medical Director not covered by Part B. | Added January 2013 | |
90750** | Zostavax (recombinant form) | Per Carrier Medical Director not covered by Part B. | Added February 2018 | |
91303** | Janssen COVID-19 Vaccine | 0.5 ML | 0.01 | Added September 2021 |
A2001 - A2010** | Hydrogel Wound Dressing (Amerigel) Polyethylene Glycol 400 |
1 OZ | Invoice | Added January 2022 - See note: 4 |
A2011** | Supra sdrm | Invoice | Added May 2022 - See Note: 4 | |
A9500** | Tc99m sestamibi | per study dose | Invoice | Added February 2020 |
A9502** | Tc99m tetrofosmin | per study dose | Invoice | Added February 2020 |
A9513** | lutetium lu 177 dotatate (Lutathera) | 1 MCI | $ 274.328 | Updated dosage and pricing eff 01/01/2019 Updated pricing Eff June 2019/ Updated price July 2019 / Updated April 2020 / Updated pricing Eff January 2021 |
A9516** | Iodine I-123 Sodium Iodide, diagnostic, per 100 microcuries, up to 999 microcuries is a radiopharmaceutical drug | Invoice | Added October 2021 | |
A9583** | Gadofosveset trisodium inj (Ablavar) | 1 ML | Invoice | Added November 2019 |
A9587** | Gallium ga-68, dotatate, diagnostic, (Netspot) | 0.1 MCI | $ 68.704 | Updated pricing 10/2017 / Updated August 2019 |
A9588** | Fluciclovine f-18, diagnostic (Axumin) | PER MCI | Invoice | Changed pricing to invoice |
A9595** | Piflufolastat f-18, diagnostic, 1 millicurie | Per MCI | Invoice | Added July 2022 |
A9606** | Radium Ra 223 dichloride (Xofigo) | MicroCurie | $ 150.859 | Eff:1/1/2015 / Pricing change EFF 10/01/17 / price change 7/2018 / Updated August 2019 / Updated April 2020 / Updated October 2020 / Updated January 2021 / Updated October 2021 |
C9076** | Lisocabtagene maraleucel (Breyanzi) | Should be billed to Part A | Added August 2021 | |
G2216** | Naloxone - injectable | 1 MG | $ 11.226 | Added January 2021 |
J0120** | Tetracycline | Invoice | Added January 2020 | |
J0130** | Abciximab injection (Reopro) | 10 MG | Invoice | Added April 2020 |
J0135** | Adalimumab injection 20 MG (Humira) | Considered self-administered. | Added November 2019 | |
J0200** | Alatrofloxacin mesylate (Trovan IV) | 100 MG | Invoice | |
J0205** | Alglucerase injection (Ceredase) | 10 UNITS | Invoice | Added November 2019 |
J0210** | Methyldopate hcl injection | 250 MG | $ 42.400 | Added January 2020 |
J0215** | Alefacept (Amevive) | 0.5 MG | Invoice | Added November 2019 |
J0220** | Alglucosidase alfa | 10 MG | Invoice | Added April 2020 |
J0270** | Alprostadil, 1.25 MCG (Caverjet, Edex) | Considered self-administered. | ||
J0275** | Alprostadil Urethral Suppository | Considered self-administered. | ||
J0282** | Amiodarone Hcl | 30 MG | $ 0.424 | Updated August 2019 |
J0288** | Ampho b cholesteryl sulfate (Amphotec) | 10 MG | Invoice | Added November 2019 |
J0364** | Apomorphine Hydrochloride (Apokyn) | Considered self-administered. | Added November 2019 | |
J0364** | Apomorphine Hydrochloride (Apokyn) | Considered self-administered. | Added January 2020 | |
J0365** | Aprotinin (Trasylol) | 10000 KIU | Invoice | Added November 2019 |
J0380** | metaraminol bitartrate, inj (Aramine) | 10 MG | Invoice | |
J0390** | Chloroquine injection (Aralen Hcl) | 250 MG | Invoice | |
J0395** | Arbutamine HCl injection (Genesa) | 1 MG | Invoice | |
J0400** | Aripiprazole injection (Abilify) | 0.25 MG | Invoice | Added November 2019 |
J0520** | Bethanechol chloride inject | Oral drug considered part of procedure in physician's office. | ||
J0573** | Buprenorphine/naloxone (Suboxone) | Considered part of procedure. | Added March 2020 | |
J0574** | Buprenorphine/Naloxone | Considered self-administered. | Added November 2019 | |
J0593** | Inj., lanadelumab-flyo, 1 mg (Takhzyro) | Considered self-administered. | Added October 2019 / Updated January 2020 | |
J0599** | Injection, C-1 esterase inhibitor (human) (Haegarda) | Considered self-administered. | Added January 2020 | |
J0620** | Calcium glycerophosphate/Calcium lactate (Calphosan) | 10 ML | Invoice | |
J0630** | Calcitonin salmon injection (Miacalcin) | Considered self-administered. | Added November 2019 | |
J0698** | Cefotaxime sodium injection | 1 GM | Invoice | CMS stopped pricing October 2021 |
J0706** | Caffeine citrate injection (Cafcit) | 5 MG | $ 1.855 | Added January 2020 |
J0715** | Ceftizoxime sodium / 500 MG (Cefizox) | 500 MG | Invoice | Added October 2020 |
J0745** | Inj codeine phosphate / 30 MG | 30 MG | Invoice | Added January 2020 |
J0795** | Corticorelin ovine triflutal (Acthrel) | 100 MCG | $ 967.314 | CMS stopped pricing October 2021 |
J0800** | Corticotropin injection (Acthar) | Considered self-administered. | Added January 2020 | |
J0890** | Peginesatide injection (Omontys) | 0.1 MG | Invoice | Added November 2019 |
J0945** | Brompheniramine Maleate | 10 MG | Invoice | Added November 2019 |
J1094** | Dexamethasone Acetate | 1 MG | Invoice | Added November 2019 |
J1095** | Dexamethasone (Dexycu) | 1 MCG | $ 1,261.400 | Added October 2022 |
J1096** | Dexametha opth insert 0.1 mg (Dextenza) | 0.1 MG | $ 147.075 | Added October 2019 / Updated December 2021 |
J1097** | Phenylep ketorolac opth soln (Omidria) | 1 ML | $ 123.225 | Added October 2019 |
J1130** | Diclofenac sodium | 0.5 MG | Invoice | Added 05/2017 / Updated August 2019 |
J1260** | Dolasetron mesylate (Anzemat) | 10 MG | $ 6.214 | Added November 2019 |
J1267** | Doripenem injection | 10 MG | Invoice | Added November 2019 / Updated October 2020 |
J1302** | Enjaymo (Sutimlimab-jome) | 10 MG | 16.855 | Added December 2022 |
J1324** | Enfuvirtide (Fuzeon) | Considered self-administered. | ||
J1327** | Eptifibatide injection (Integrilin) | 5 MG | $ 24.907 | Added November 2019 |
J1330** | Ergonovine maleate, injection | 1 GM | Invoice | Added August 2019 |
J1438** | Etanercept injection (Enbrel) | Considered self-administered. | Added November 2019 | |
J1443** | Ferric Pyrophosphate Citrate Sol (Triferic) | 0.1 MG | Invoice | |
J1444** | Inj, ferric pyrophosphate citrate powder, 0.1 mg of iron | 0.1 MG | Invoice | Added July 2019 |
J1451** | Fomepizole, 15 mg | 15 MG | $ 11.357 | Added November 2019 |
J1455** | Foscarnet sodium injection (Foscavir) | 1000 MG | $ 82.679 | Added November 2019 / Updated January 2021 |
J1457** | Gallium nitrate injection (Ganite) | 1 MG | Invoice | Added November 2019 |
J1559** | Hizentra injection | Considered self-administered. | Added January 2020 | |
J1562** | Injection, Immune Globulin (Vivaglobin) | Considered self-administered. | Added January 2020 | |
J1573** | Hepagam b intravenous, inj | 0.5 ML | $ 65.605 | Added November 2019 |
J1590** | Gatifloxacin injection | Considered self-administered. | End Date 12/31/2016 | |
J1595** | Injection glatiramer acetate (Copaxone, Glatopa) | Considered self-administered. | ||
J1600** | Gold sodium thiomaleate inj | 50 MG | Invoice | Added November 2019 |
J1628** | Guselkumab (Tremfya) | 1 ML | $ 12,075.064 | Added October 2019 / Updated April 2020 |
J1675** | Histrelin Acetate (Supprelin) | Considered self-administered. | ||
J1680** | fibrinogen concentrate human | 100 MG | $ 103.550 | End Date 12/31/2012 |
J1700** | Hydrocortisone acetate inj | 25 MG | Invoice | Updated August 2019 |
J1710** | Hydrocortisone sodium ph inj | 50 MG | Invoice | |
J1726** | Hydroxyprogesterone Caproate (Makena) | 10 MG | $ 28.940 | Added January 2018 / Updated August 2019 / Updated October 2020 |
J1741** | Ibuprofen injection | Considered self-administered. | Added January 2020 | |
J1744** | Injection, Icatibant, 1 mg (Firazyr) | Considered self-administered. | Added January 2020 | |
J1790** | Droperidol injection | 5 MG | $ 7.918 | Added November 2019 / Updated October 2020 |
J1815** | Insulin injection | Considered self-administered. | Added January 2020 | |
J1817** | Insulin for insulin pump use | Considered self-administered. | Added January 2020 | |
J1823** | Nebilizumab-cdon (Uplizna) | 10 MG | 4628.67 | Added January 2021 - Effective 6/11/2020 |
J1826** | Interferon beta-1a / 30 mcg (Avonex) | Considered self-administered. | Updated August 2019 | |
J1830** | Interferon beta-1b / .25 MG (Betaseron, Extavia) | Considered self-administered. | ||
J1833** | Isavuconazonium Sulfate (Cresemba) | 1 MG | $ 0.899 | Updated August 2019 |
J1840** | Kanamycin sulfate 500 MG inj (Kantrex) | 500 MG | Invoice | Added November 2019 |
J1850** | Kanamycin sulfate 75 MG inj (Kantrex) | 75 MG | Invoice | Added November 2019 |
J1890** | Cephalothin sodium injection | 1 G | Invoice | |
J1945** | Lepirudin (Refludan) | 50 MG | Invoice | Added November 2019 |
J1952** | Leuprolide (Camcevi) | 1 MG | 95.643 | Added Decembef 2022 |
J1960** | Levorphanol tartrate | 2 MG | Invoice | Updated August 2019 |
J1990** | Chlordiazepoxide injection | 100 MG | Invoice | |
J2170** | Mecasermin (Increlex) | Considered self-administered. | ||
J2180** | Meperidine and Promethazine hcl | 50 MG | Invoice | Added November 2019 |
J2212** | Injection, Methylnaltrexone, 0.1 mg (Relistor) | Considered self-administered. | Added January 2020 | |
J2265** | Minocycline Hydrochloride (Minocin) | Considered self-administered. | ||
J2278** | Ziconotide injection | 1 MCG | $ 8.395 | Updated April 2021 |
J2320** | Nandrolone decanoate 50 MG | 50 MG | Invoice | Updated August 2019 |
J2325** | Nesiritide injection (Natrecor) | 0.1 MG | Invoice | Added December 2019 |
J2326** | Nusinersen (Spinraza) | 0.1 MG | 1126.250 | Added July 2022 |
J2354** | Octreotide Acetate inj, non-depot (Sandostatin) | Considered self-administered. | Added December 2019 | |
J2355** | Oprelvekin injection (Neumega) | 5 MG | Invoice | Added December 2019 |
J2356** | Tezepelumab-ekko (Tezspire) | 1 MG | 18.338 | Added July 2022 / Eff 1/4/2022 |
J2370** | Phenylephrine hcl injection (Biorphen/Vazculep) | 1 ML | $ 0.742 | Eff. Date 11/1/2019 - Added December 2019 / Updated October 2020 |
J2410** | Oxymorphone hcl injection (Numorphan hcl/Opana) | 1 MG | Invoice | Added December 2019 |
J2440** | Papaverin hcl injection | Considered self-administered. | Added December 2019 / Updated January 2020 | |
J2502** | Pasireotide (Signifor LAR) | 1 MG | $ 230.698 | Updated August 2019 / Updated April 2020 / Updated October 2020 |
J2504** | Pegademase bovine (Adagen) | 25 IU | $ 367.961 | Added April 2020 |
J2513** | Pentastarch 10% solution (Pentaspan) | 10% | Invoice | |
J2547** | Peramivir (Rapivab) | 1 MG | $ 1.678 | |
J2590** | Oxytocin injection (Pitocin) | 10 UNITS | $ 0.919 | Added January 2019 / Updated August 2019 / Updated April 2020 / Updated October 2020 |
J2650** | Prednisolone acetate (Cotolone/Key-Pred) | 1 ML | Invoice | Updated August 2019 |
J2670** | Tolazoline hcl injection | 25 MG | Invoice | |
J2730** | Pralidoxime chloride inj (Protopam Chloride) | 1 GM | $ 91.902 | Added December 2019 |
J2797** | Rolapitant (Varubi) | 0.5 MG | Invoice | Added January 2019 / Updated August 2019 / Updated April 2020 / Updated October 2020 |
J2810** | Inj theophylline per 40 MG | 40 MG | Invoice | Added January 2020 |
J2840** | Seblipase alfa (Kanuma) | 1 MG | $ 541.130 | Added January 2017 / Updated August 2019 |
J2850** | Inj secretin synthetic human (Chirhostim) | 1 MCG | $ 27.494 | Added December 2019 |
J2940** | Somatrem injection | Considered self-administered. | ||
J2941** | Somatropin injection | Considered self-administered. | ||
J2950** | Promazine HCL (Sparine) | 25MG | Invoice | |
J2993** | Reteplase injection (Retavase) | 18.1 MG | Invoice | Added January 2020 |
J3030** | Sumatriptan Succinate (Imitrex) | Considered self-administered. | ||
J3031** | Inj. Fremanezumab-vfrm (Ajovy) | Considered self-administered. | Added October 2019 / Updated January 2020 | |
J3070** | Pentazocine injection | 30 MG | Invoice | Added January 2020 |
J3110** | Teriparatide injection (Forteo) | Considered self-administered. | ||
J3246** | Tirofiban Hcl (Aggrastat) | 0.25 MG | $ 10.978 | Added January 2020 |
J3265** | Injection torsemide 10 mg/ml (Demadex) | 10 MG | Invoice | Updated August 2019 |
J3280** | Thiethylperazine maleate, inj (Norzine, Torecan) | 10 MG | Invoice | |
J3299** | Triamcinolone acetonide (Xipere) | 1 MG | 43.725 | Added July 2022 |
J3303** | Triamcinolone hexacetonl inj (Aristospan) | 5 MG | Invoice | Added January 2020 |
J3310** | Perphenazine (Trilafon) | 5 MG | Invoice | Updated January 2020 |
J3355** | Urofollitropin, 75 iu (Bravelle) | Considered self-administered. | Added January 2020 | |
J3365** | Urokinase 250,000 IU inj (Abbokinase) | 250000 IU | Invoice | Added January 2020 |
J3470** | Hyaluronidase injection (Amphadase) | 150 UNITS | $ 59.148 | Added January 2020 |
J7100** | Dextran 40 infusion (LMD in dextrose) | 500 ML | $ 28.262 | Added January 2020 / Updated January 2021 |
J7110** | Dextran 75 infusion | 500 ML | Invoice | Added January 2020 |
J7121** | 5% Dextrose in lactated ringers | 1000 CC | Invoice | |
J7130** | Hypertonic saline solution | 20 CC | Invoice | |
J7131** | Hypertonic saline solution | 1 ML | Invoice | Added January 2020 |
J7191** | Factor viii (porcine) (Hyate:C) | 1 IU | Invoice | |
J7296** | Levonorgestrel releasing intrauterine contraceptive system, (Kyleena) | 19.5 MG | $ 1,010.721 | Added January 2018 / Updated August 2019 |
J7309** | Methyl Aminolevulinate, top (Metvixia) | 1 GM | Invoice | Added January 2020 |
J7310** | Ganciclovir long act implant (Vitrasert) | 4.5 MG | Invoice | Added January 2020 |
J7315** | Mitomycin - ophthalmic 0.2 mg topical solution | Considered part of procedure | Added September 2018 | |
J7318** | Hyaluronic acid (Durolane) | 1 MG | $ 17.225 | Added January 2019 / Updated June 2019 |
J7320** | Hyaluronate sodium or derivative (Genvisc 850) | 1 MG | $ 16.918 | Added October 2018 / Updated pricing 04/15/2019 |
J7322** | Hyaluronic acid (Hymovis) | 1 MG | $ 31.668 | Added January 2017 / Updated July 2017 / Updated August 2019 |
J7326** | Hyaluronate sodium (Gel-One) | per dose-30 MG/3 ML | $ 1,219.000 | Added January 2019 / Updated June 2019 / Updated October 2020 |
J7328** | Hyaluronan or derivative, gel-syn (Gelsyn-3) | 0.1 MG | $ 2.177 | |
J7329** | Hyaluronate sodium (Trivisc) | 1 MG | $ 19.120 | Added January 2021 - Effective 12/1/2020 / Updated April 2021 |
J7330** | Cultured chondrocytes implnt (Maci) | 1 EA | Invoice | Added January 2020 |
J7332** | Inj., triluron, 1 mg | 1 MG | $ 25.917 | Added October 2019 |
J7333** | Hyaluronate Sodium (Visco-3) | 25 MG | $ 352.980 | Added July 2020 |
J7401** | Propel, Propel Contour, Propel Mini | 10 MCG | $ 10.775 | END DATE 3/31/2021 |
J7500** | Azathioprine oral 50 mg (Azasan) | Should be billed to DMAC. | Added January 2020 | |
J7501** | Azathioprine parenteral | 100 MG | $ 265.000 | Added January 2020 |
J7502** | Cyclosporine oral 100 mg | Should be billed to DMAC. | Added January 2020 | |
J7503** | Tacrol envarsus (Envarsus XR) | Considered self-administered. | Added January 2020 | |
J7505** | Monoclonal anitibodies | 5 MG | Invoice | Added January 2020 |
J7507** | Tacrolimus oral per 1 mg (Prograf) | Should be billed to DMAC. | Added January 2020 | |
J7508** | Tacrolimus Ex Rel oral 0.1 mg (Astagraf XL) | Should be billed to DMAC. | Added January 2020 | |
J7509** | Methylprednisolone oral | Should be billed to DMAC. | Added January 2020 | |
J7510** | Prednisolone oral per 5 mg | Should be billed to DMAC. | Added January 2020 | |
J7512** | Prednisone ir or dr oral 1 mg | Considered self-administered. | Added January 2020 | |
J7513** | Daclizumab, parenteral (Zenapax, Zinbryta) | 25 MG | Invoice | Added January 2020 |
J7515** | Cyclosporine oral 25 mg | Should be billed to DMAC. | Added January 2020 | |
J7517** | Mycophenolate mofetil oral (Cellcept) | Should be billed to DMAC. | Added January 2020 | |
J7518** | Mycophenolic acid (Myfortic) | Should be billed to DMAC. | Added January 2020 | |
J7520** | Sirolimus, oral (Rapamune) | Should be billed to DMAC. | Added January 2020 | |
J7527** | Oral Everolimus (Afinitor, Zortress) | Should be billed to DMAC. | Added January 2020 | |
J7604 - J7699** | Inhalation Solutions | Considered part of procedure in physician's office. | Updated March 2019 | |
J8499** | Estramustine Phosphate Sodium (Emcyt) | Should be billed to DMAC. | Added January 2020 | |
J8501** | Oral aprepitant (Emend) | Should be billed to DMAC. | Added January 2020 | |
J8510** | Oral busulfan (Myleran) | Should be billed to DMAC. | Added January 2020 | |
J8520** | Capecitabine, oral, 150 mg (Xeloda) | Should be billed to DMAC. | Added January 2020 | |
J8521** | Capecitabine, oral, 500 mg (Xeloda) | Should be billed to DMAC. | Added January 2020 | |
J8530** | Cyclophosphamide oral 25 mg | Should be billed to DMAC. | Added January 2020 | |
J8540** | Oral dexamethasone (Hidex, Taperdex) | Should be billed to DMAC. | Added January 2020 | |
J8560** | Etoposide oral 50 mg | Should be billed to DMAC. | Added January 2020 | |
J8561** | Everolimus, 0.25 MG | Should be billed to DMAC. | End Date 12/31/2012 | |
J8562** | Oral fludarabine phosphate (Oforta) | Should be billed to DMAC. | Added January 2020 | |
J8600** | Melphalan oral 2 mg (Alkeran) | Should be billed to DMAC. | Added January 2020 | |
J8610** | Methotrexate oral 2.5 mg (Xatmep, Trexall) | Should be billed to DMAC. | Added January 2020 | |
J8655** | Netupitant Palonosetron oral (Akynzeo) | Should be billed to DMAC. | Added January 2020 | |
J8700** | Temozolomide (Temodar) | Should be billed to DMAC. | Added January 2020 | |
J8705** | Topotecan oral (Hycamtin) | Should be billed to DMAC. | Added January 2020 | |
J9015** | Aldesleukin injection (Proleukin) | 1 EA | $ 4,964.616 | Added January 2020 |
J9020** | Asparaginase injection (Elspar) | 10000 UNITS | Invoice | Added January 2020 |
J9057** | Copanlisib (Aliqopa) | 1 MG | $ 82.420 | Added January 2019 / Updated August 2019 |
J9098** | Cytarabine liposome inj (Depocyt) | 10 MG | Invoice | Added January 2020 |
J9118** | Inj. Calaspargase pegol-mknl (Asparlas) | 10 UNITS | $ 67.840 | Added October 2019 / Updated January 2020 |
J9151** | Daunorubicin citrate inj (Daunoxome) | 10 MG | Invoice | Added January 2020 / Updated December 2021 |
J9160** | Denileukin diftitox inj (Ontak) | 300 MCG | Invoice | Added January 2020 |
J9165** | Diethylstilbestrol diphosphate injection (Stilphostrol) | 250 MG | Invoice | |
J9175** | Elliotts b solution per ml | 1 ML | $ 8.373 | Added January 2020 |
J9198** | gemcitabine hydrochloride (Infugem) | 100MG | $ 40.280 | Added March 2021 / CMS priced April 2021 |
J9199** | Gemcitabine Hydrochloride (Infugem) | 200 MG | $ 80.560 | Added March 2020 |
J9212** | Inj., interferon alfacon-1, recomb, 1 mcg (Pegasys) | Considered self-administered. | Added January 2020 | |
J9213** | Interferon alfa-2a inj (Roferon-A) | Considered self-administered. | Updated January 2020 | |
J9215** | Interferon, alfa-n3 (Alferon-N) | 250,000 IU | $ 31.800 | Updated August 2019 |
J9216** | Injection, interferon, gamma 1-B, 3 million units (Actimmune) | Considered self-administered. | Added January 2020 | |
J9218** | Leuprolide acetate injection (Lupron) | Considered self-administered. | Added January 2020 | |
J9219** | Leuprolide acetate implant | 65 MG | Invoice | Added January 2020 |
J9230** | Mechlorethamine hcl inj (Mustargen) | 10 MG | Invoice | Added January 2020 |
J9270** | Plicamycin inj (Mithracin) | 2.5 MG | Invoice | |
J9304** | Pemetrexed (Pemfexy) | 10 MG | $ 203.907 | Added March 2022 / Eff. 2/1/2022 |
J9315** | Romidepsin injection (Istodax) | END DATED 9/30/2021 | ||
J9600** | Porfimer Sodium injection (Photofrin) | 75 MG | $ 22,302.400 | Updated August 2019 |
P9043** | Plasma protein fract, 5%, 50 ml (Plasmanate 50 ml) | 50 ML | $ 23.871 | Added January 2020 |
P9048** | Plasma protein fract, 5%, 250 ml (Plasmanate 250 ml) | 250 ML | $ 56.063 | Added January 2020 |
Q0163** | Diphenhydramine HCl 50mg (Alercap, Banophen, Benadryl) | Should be billed to DMAC. | Added January 2020 | |
Q0164** | Prochlorperazine maleate 5mg | Should be billed to DMAC. | Added January 2020 | |
Q0166** | Granisetron hcl 1 mg oral | Should be billed to DMAC. | Added January 2020 | |
Q0167** | Dronabinol 2.5mg oral (Marinol) | Should be billed to DMAC. | Added January 2020 | |
Q0169** | Promethazine HCl 12.5mg oral | Should be billed to DMAC. | Added January 2020 | |
Q0174** | Thiethylperazine maleate, 10mg | Should be billed to DMAC. | ||
Q0179** | Ondansetron hcl 8 mg oral | Should be billed to DMAC. | End Date 12/31/2011 | |
Q0180** | Dolasetron mesylate oral (Anzemet) | Should be billed to DMAC. | Added January 2020 | |
Q0181** | Unspecified oral dosage form, FDA approved presription anti-emetic | Should be billed to DMAC. | ||
Q0515** | Sermorelin acetate injection | 1 MCG | Invoice | Added January 2020 |
Q2009** | Fosphenytoin inj PE (Cerebyx) | 50 MG | $ 5.062 | Added January 2020 |
Q2017** | Teniposide, 50 mg | 50 MG | $ 2,645.707 | Added January 2020 |
Q2026** | Radiesse injection | 0.1 ML | Invoice | |
Q2028** | Sculptra | 0.5 MG | Invoice | |
Q2033** | Flublok (quadravalent form) | 0.5 ML | Invoice | Added January 2020 |
Q2034** | Agriflu | 0.05 ML | Invoice | |
Q2035** | Afluria vacc, 3 yrs & >, im | 0.5 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
Q2036** | Flulaval Quadrivalent 3 yrs & >, im | 0.05 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
Q2037** | Fluvirin vacc, 3 yrs & >, im | 0.5 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
Q2038** | Fluzone vacc, 3 yrs & >, im | 0.5 ML | Invoice | No new pricing available for the 2021-2022 flu season. |
Q2039** | Not Otherwise Classified flu vacc, 3 yrs & >, im | 0.5 ML | Invoice | Updated November 2021 |
Q2040** | tisagenlecleucel (Kymriah) | Per infusion | $503,500.000 | Added January 2018 / End Date 12/31/2018 |
Q2041** | Axicabtagene ciloleucel (Yescarta) | Should be billed to Part A. | Added August 2021 | |
Q2042** | Tisagenlecleucel (Kymriah) | Should be billed to Part A. | Added August 2021 | |
Q2047** | Peginesatide injection (Omontys) | 0.1 MG | Invoice | End Date 12/31/2012 |
Q2049** | Imported Lipodox injection | 10 MG | $ 508.429 | Added January 2020 |
Q2053** | Brexucabtagene autoleucel (Tecartus) | Should be billed to Part A | Added April 2021 / Updated August 2021 | |
Q4074** | Iloprost non-comp unit dose (Ventavis) | Considered part of procedure in physician's office. | Added January 2020 | |
Q4100** | Skin substitutes; not otherwise specified | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
Q4103** | Oasis Burn Matrix | 1 SQ CM | Invoice | Added May 2019 |
Q4104** | Integra BMWD skin sub | 1 SQ CM | Invoice | Added January 2020 / See Note: 4 |
Q4105** | Integra Omnigraft | 1 SQ CM | Invoice | See Note: 4 |
Q4107** | Graftjacket skin sub | 1 SQ CM | Invoice | Added January 2020 / See Note: 4 |
Q4108** | Integra matrix skin sub | 1 SQ CM | Invoice | Added January 2020 / See Note: 4 |
Q4112** | Cymetra allograft | 1 CC | Invoice | Added January 2020 / See Note: 4 |
Q4113** | Graftjacket express allograf | 1 CC | Invoice | Added January 2020 / See Note: 4 |
Q4114** | Integra flowable wound matri | 1 CC | Invoice | Added May 2019 / See Note: 4 |
Q4116** | Alloderm skin sub | 1 SQ CM | Invoice | Added May 2019 / See Note: 4 |
Q4117** | Hyalomatrix | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4118** | Matristem Micromatrix | 1 MG | Invoice | See Note: 4 |
Q4119** | Matristem Micromatrix | 1 SQ CM | Invoice | End Date 12/31/2016 |
Q4122** | Dermacell, awm porous sq cm | 1 SQ CM | Invoice | See Note: 4 |
Q4123** | Alloskin RT | 1 SQ CM | Invoice | Added May 2019 |
Q4124** | Oasis Ultra Tri-Layer Wound Matrix | 1 SQ CM | Invoice | See Note: 4 |
Q4125** | Arthroflex | 1 SQ CM | Invoice | See Note: 4 |
Q4126** | Memoderm | 1 SQ CM | Invoice | See Note: 4 |
Q4127** | Talymed | 1 SQ CM | Invoice | See Note: 4 |
Q4128** | Flex HD or Allopatch HD | 1 SQ CM | Invoice | See Note: 4 |
Q4129** | Unite Biomatrix | 1 SQ CM | Invoice | End Date 12/31/2016 |
Q4130** | Strattice TM | 1 SQ CM | Invoice | See Note: 4 |
Q4131** | Epifix | 1 SQ CM | Invoice | End Date 12/31/2018 |
Q4136** | E-Z Derm | 1 SQ CM | Invoice | Added 04/05/2018 |
Q4138** | Biodfence dryflex | 1 SQ CM | Invoice | See Note: 4 |
Q4139* | Amniomatrix or Biodmatrix | 1 CC | Invoice | See Note: 4 |
Q4140** | Biodfence | 1 SQ CM | Invoice | See Note: 4 |
Q4141** | Alloskin ac | 1 SQ CM | Invoice | See Note: 4 |
Q4142** | Xcm Biologic Tissue Matrix | 1 SQ CM | Invoice | See Note: 4 |
Q4143** | Repriza | 1 SQ CM | Invoice | See Note: 4 |
Q4146** | Tensix | 1 SQ CM | Invoice | See Note: 4 |
Q4147** | Architect Extracellular Matrix | 1 SQ CM | Invoice | See Note: 4 |
Q4148** | Neox 1k | 1 SQ CM | Invoice | See Note: 4 |
Q4149** | Excellagen | 0.1 CC | Invoice | See Note: 4 |
Q4152** | Dermapure | 1 SQ CM | Invoice | See Note: 4 |
Q4153** | Dermavest and Plurivest | 1 SQ CM | Invoice | Added April 2020 / See Note: 4 |
Q4158** | Kerecis Omega3 Wound (Marigen) | 1 SQ CM | Invoice | See Note: 4 |
Q4159** | Affinity | 1 SQ CM | Invoice | Added April 2020 / See Note: 4 |
Q4161** | Bio-connekt | 1 SQ CM | Invoice | See Note: 4 |
Q4162** | Amnio bio, woundex flow | 1 SQ CM | Invoice | See Note: 4 |
Q4164** | Helicoll | 1 SQ CM | Invoice | See Note: 4 |
Q4165** | Keramatrix | 1 SQ CM | Invoice | See Note: 4 |
Q4166** | Cytal Wound/Burn Matrix | 1 SQ CM | Invoice | Added January 2020 / See Note: 4 |
Q4169** | Artacent Wound | 1 SQ CM | Invoice | Added 07/2018 |
Q4170** | Cygnus | 1 SQ CM | Invoice | Added April 2020 / See Note: 4 |
Q4172** | PuraPly | 1 SQ CM | Invoice | End Date 12/31/2018 |
Q4173** | Palingen or Palingen Xplus | 1 SQ CM | Invoice | Updated September 2021 - CMS stopped pricing July 2021 |
Q4175** | MicroDerm | 1 SQ CM | Invoice | Added 10/17 |
Q4176** | Neopatch | 1 SQ CM | Invoice | Added January 2018 |
Q4177** | Floweramnioflo | 0.1 CC | Invoice | Added January 2018 |
Q4178** | Floweraminopatch | 1 SQ CM | Invoice | Added January 2018 |
Q4179** | Flowerderm | 1 SQ CM | Invoice | Added January 2018 |
Q4180** | Revita | 1 SQ CM | Invoice | See Note: 4 |
Q4181** | Amino wound | 1 SQ CM | Invoice | Added January 2018 |
Q4182** | Transcyte | 1 SQ CM | Invoice | Added January 2018 |
Q4184** | Cellesta or duo per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4197** | Puraply XT | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
Q4201** | Matrion per sq cm | 1 SQ CM | Invoice | Added January 2022 / See Note: 4 |
Q4203** | Geistlich Derma-Gide 1 sq cm | 1 SQ CM | Invoice | Added October 2020 / See Note: 4 |
Q4204** | Xwrap, per square centimeter | 1 SQ CM | Invoice | Added November 2022 / See Note: 3 |
Q4205** | Membrane graft or wrap sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4206** | Fluid flow or fluid gf | 1 ML | $ 2,120.000 | Added October 2019 / Updated June 2020 / Updated September 2020 |
Q4208** | Novafix per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4209** | Surgraft per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4210** | Axolotl graf dualgraf sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4211** | Amnion bio or axobio sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4212** | Allogen, per cc | 1 CC | Invoice | Added October 2019 / See Note: 4 |
Q4213** | Ascent, 0.5 mg | 0.5 MG | $ 65.720 | Updated December 2019 / Eff. 5/28/2020 - Updated June 2020 / Updated October 2020 |
Q4214** | Cellesta cord per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4215** | Axolotl ambient, cryo 0.1 mg | 0.1 MG | Invoice | Added October 2019 / See Note: 4 |
Q4216** | Artacent cord per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4217** | Woundfix biowound plus xplus | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4218** | Surgicord per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4219** | Surgigraft dual per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4220** | Bellacell HD, Surederm sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4221** | Amniowrap2 per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4222** | Progenamatrix, per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4226** | Myown harv prep proc sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
Q4231** | Corplex P | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
Q4232** | Corplex | 1 SQ CM | Invoice | Added June 2020 / See Note: 4 |
Q4234 | Xcellerate amniotic membrane human | Invoice | Added July 2021 See Note: 4 | |
Q4237** | Cyro-Cord | 1 SQ CM | Invoice | Added July 2020 / See Note: 4 |
Q4238** | Derm-Maxx | 1 SQ CM | Invoice | Added July 2020 / See Note: 4 |
Q4239** | Amnio-Maxx or Amnio-Maxx Lite | 1 SQ CM | Invoice | Added July 2020 / See Note: 4 |
Q4244** | Procenta | Non FDA Approved | Added March 2022 | |
Q4246** | Coretext or protex | Non FDA Approved | Added February 2022 | |
Q4248** | Dermacyte amniotic membrane allograft | Invoice | Added July 2022 | |
Q4253** | Zenith amniotic membrane | Invoice | Added December 2021 / Updated June 2022. Covered Eff. 10/01/2021 / See Note: 4 | |
Q4254** | Novafix per sq cm | Considered investigational | Added September 2021 | |
Q9953** | Iron Based Magnetic Resonance Contrast Agent | 1 ML | Invoice | |
Q9954** | Oral MR contrast, 100 ml | 100 ML | Invoice | Added January 2020 |
Q9955** | Inj perflexane lip micros, ml (Imagent) | 1 ML | Invoice | |
Q9962** | HOCM 300-349 mg/ml iodine, 1 ml | 1 ML | Invoice | Added January 2020 |
Q9968** | Inj Non-Radioactive, Non contrast | Invoice | Added January 2020 | |
Q9969** | Tc-99m from non-highly uranium source | Invoice | Added January 2020 | |
Q9980** | Genvisc | 1 MG | $ 9.765 | End Date 12/31/2016 |
Q9985** | Hydroxyprogesterone Caporate (other forms) | Invoice | End Date 12/31/2017 | |
Q9986** | Hydroxyprogesterone Caporate (Makena) | 10 MG | $ 32.408 | End Date 12/31/2017 |
Q9988** | Platelets, Pathogen Reduced | Invoice | End Date 12/31/2017 |