Table III: 2019 Medicare Drug Fee Schedule* CY st Quarter Average Sales Price (ASP) Data Plus 6 Percent

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Elfreda Chandler
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1 Table III: 2019 Medicare Drug Fee Schedule* CY st Quarter Average Sales Price (ASP) Data Plus 6 Percent *The Medicare payments allowance limits are effective Jan. 1 thru March. 31, CY 2019 Effective Jan. 1 Through Mar. 31 Code Description Code Dosage ASP plus 6 percent J0129 Abatacept 10mg $51.61 J0130 Abciximab injection 10mg $1, J0133 Acyclovir, 5 mg 5mg $0.05 J0171 Adrenalin epinephrin inject 0.1mg $0.74 J0207 Amifostine 500mg $ J0256 Alpha 1 proteinase inhibitor 10mg $4.55 J0280 Aminophyllin 250 MG inj 250mg $7.02 J0289 Amphotericin b liposome inj 10mg $22.19 J0295 Ampicillin sodium per 1.5 gm 1.5gm $2.62 J0360 Hydralazine hcl injection 20mg $2.58 J0456 Azithromycin 500mg $2.76 J0461 Atropine sulfate injection 0.01mg $0.07 J0475 Baclofen 10 MG injection 10mg $ J0476 Baclofen intrathecal trial 50mcg $44.35 J0480 Basiliximab 20mg $3, J0490 Belimumab 10mg $44.16 J0500 Dicyclomine injection 20mg $69.65 J0515 Inj benztropine mesylate 1mg $18.67 J0570 Buprenorphine implant 74.2mg $1, J0583 Bivalirudin 1mg $0.80 J0585 Botulinum toxin a per unit 1unit $6.14 J0587 Botulinum toxin type B 100units $12.00 J0592 Buprenorphine hydrochloride 0.1mg $4.15 J0595 Butorphanol tartrate 1 mg 1mg $2.62 J0600 Edetate calcium disodium inj 1000mg $5, J0610 Calcium gluconate injection 10ml $4.36 J0630 Calcitonin salmon injection 400units $2, J0636 Inj calcitriol per 0.1 mcg 0.1mcg $0.45 J0637 Caspofungin acetate 5mg $10.02 J0640 Leucovorin calcium injection 50mg $3.35 J0690 Cefazolin sodium injection 500mg $0.83 J0692 Cefepime HCl for injection 500mg $2.47 J0694 Cefoxitin sodium injection 1gm $3.54 J0696 Ceftriaxone sodium injection 250mg $0.65 J0697 Sterile cefuroxime injection 750mg $2.09 J0702 Betamethasone acet&sod phosp 3mg $6.89 J0713 Inj ceftazidime per 500 mg 500mg $2.10 J0717 Certolizum Pegol Inj 1mg $7.89 J0720 Chloramphenicol sodium injec 1gm $39.34 J0725 Chorionic gonadotropin/1000u 1,000units $22.60 J0740 Cidofovir injection 375mg $ J0743 Cilastatin sodium injection 250mg $6.95 J0770 Colistimethate sodium inj 150mg $15.30

2 J0780 Prochlorperazine injection 10mg $10.06 J0800 Corticotropin injection 1-40units $3, J0882 Darbepoetin alfa, non-esrd 1mcg $3.83 J0885 Non esrd epoetin alpha inj 1,000units $11.95 J0895 Deferoxamine mesylate inj 500mg $9.62 J0897 Denosumab injection 1 mg $18.61 J1000 Depo-estradiol cypionate inj 5mg $21.94 J1020 Methylprednisolone 20 MG inj 20mg $4.01 J1030 Methylprednisolone 40 MG inj 40mg $6.60 J1040 Methylprednisolone 80 MG inj 80mg $12.86 J1100 Dexamethasone sodium phos 1mg $0.11 J1110 Inj dihydroergotamine mesylt 1mg $14.18 J1120 Acetazolamid sodium injectio 50mg $14.18 J1160 Digoxin injection 0.5mg $4.87 J1165 Phenytoin sodium injection 50mg $1.04 J1190 Dexrazoxane HCl injection 250mg $ J1200 Diphenhydramine hcl injectio 1-50mg $0.54 J1205 Chlorothiazide sodium inj 500mg $73.20 J1230 Methadone injection 10mg $73.20 J1245 Dipyridamole injection 10mg $1.67 J1250 Inj dobutamine HCL/250 mg 250mg $7.32 J1265 DopAMIne injection 40mg $0.82 J1270 Injection, doxercalciferol 1mcg $0.47 J1325 Epoprostenol injection 0.5mg $16.16 J1335 Ertapenem injection 500mg $53.61 J1364 Erythro lactobionate /500 MG 500mg $78.87 J1410 Inj estrogen conjugate 25 MG 25mg $ J1430 Ethanolamine oleate 100 mg 100mg $ J1450 Fluconazole 200mg $5.57 J1566 Inj immune globulin, lyophilzed 500mg 500mg $43.11 J1570 Ganciclovir sodium injection 500mg $56.25 J1580 Garamycin gentamicin inj 80mg $1.69 J1610 Glucagon hydrochloride/1 MG 1mg $ J1626 Granisetron HCl injection 100mcg $0.44 J1630 Haloperidol injection 5mg $1.09 J1631 Haloperidol decanoate inj 50mg $17.39 J1642 Inj heparin sodium per 10 u 10units $0.18 J1644 Inj heparin sodium per 1000u 1000units $0.20 J1645 Dalteparin sodium 2500I.U. $13.94 J1650 Inj enoxaparin sodium 10mg $0.77 J1652 Fondaparinux sodium 0.5mg $2.07 J1720 Hydrocortisone sodium succ i 100mg $12.99 J1740 Ibandronate sodium 1mg $55.44 J1742 Ibutilide fumarate injection 1mg $ J1745 Infliximab injection 10mg $76.95 J1756 Iron sucrose injection 1mg $0.24 J1786 Imuglucerase injection 10units $42.12 J1800 Propranolol injection 1mg $3.66 J1815 Insulin injection 5units $0.89 J1817 Insulin for insulin pump use 50units $10.95 J1940 Furosemide injection 20mg $0.83 J1950 Leuprolide acetate /3.75 MG 3.75mg $1,188.99

3 J1955 Inj levocarnitine per 1 gm 1gm $20.56 J1956 Levofloxacin injection 250mg $1.47 J1980 Hyoscyamine sulfate inj 0.25mg $30.29 J2001 Lidocaine injection 10mg $0.05 J2010 Lincomycin injection 300mg $13.46 J2020 Linezolid injection 200mg $8.51 J2060 Lorazepam injection 2mg $0.73 J2150 Mannitol injection 50ml $3.80 J2185 Meropenem 100mg $1.03 J2210 Methylergonovin maleate inj 0.2mg $15.77 J2250 Inj midazolam hydrochloride 1mg $0.13 J2260 Inj milrinone lactate / 5 MG 5mg $1.40 J2310 Inj naloxone hydrochloride 1mg $17.72 J2353 Octreotide injection, depot 1mg $ J2354 Octreotide inj, non-depot 25mcg $0.91 J2400 Chloroprocaine hcl injection 30ml $28.78 J2405 Ondansetron hcl injection 1mg $0.17 J2430 Pamidronate disodium /30 MG 30mg $11.91 J2501 Paricalcitol 1mcg $0.64 J2505 Injection, pegfilgrastim 6mg 6mg $4, J2507 Pegloticase injection 1mg 1mg $2, J2510 Penicillin g procaine inj 600,000units $29.29 J2515 Pentobarbital sodium inj 50mg $48.29 J2543 Piperacillin/tazobactam 1.125gm $1.94 J2560 Phenobarbital sodium inj 120mg $39.20 J2597 Inj desmopressin acetate 1mcg $12.46 J2675 Inj progesterone per 50 MG 50mg $1.85 J2680 Fluphenazine decanoate 25 MG 25mg $15.44 J2690 Procainamide hcl injection 1gm $77.30 J2700 Oxacillin sodium injection 250mg $1.93 J2765 Metoclopramide hcl injection 10mg $1.92 J2770 Quinupristin/dalfopristin 500mg $ J2780 Ranitidine hydrochloride inj 25mg $5.06 J2783 Rasburicase 0.5mg $ J2788 Rho d immune globulin 50 mcg 50mcg $28.62 J2792 Rho(D) immune globulin h, sd 100IU $27.78 J2795 Ropivacaine HCl injection 1mg $0.09 J2810 Inj theophylline per 40 MG 40mg $0.33 J2820 Sargramostim injection 50mcg $38.96 J2916 Na ferric gluconate complex 12.5mg $1.94 J2920 Methylprednisolone injection 40mg $4.87 J2930 Methylprednisolone injection 125mg $6.93 J2997 Alteplase recombinant 1mg $87.75 J3010 Fentanyl citrate injection 0.1mg $0.83 J3101 Tenecteplase injection 1mg $ J3105 Terbutaline sulfate inj 1mg $2.68 J3230 Chlorpromazine hcl injection 50mg $30.34 J3240 Thyrotropin injection 0.9mg_1.1mg $1, J3250 Trimethobenzamide hcl inj 200mg $32.77 J3260 Tobramycin sulfate injection 80mg $2.91 J3262 Tocilizumab injection 1mg $4.93 J3285 Treprostinil, 1 mg 1mg $66.12

4 J3301 Triamcinolone acetonide inj 10mg $1.70 J3315 Triptorelin pamoate 3.75mg $ J3360 Diazepam injection 5mg $6.88 J3370 Vancomycin hcl injection 500mg $4.23 J3396 Verteporfin injection 0.1mg $10.98 J3410 Hydroxyzine hcl injection 25mg $6.36 J3420 Vitamin b12 injection 1000mcg $1.74 J3430 Vitamin k phytonadione inj 1mg $4.23 J3465 Injection, voriconazole 10mg $1.78 J3475 Inj magnesium sulfate 500mg $0.55 J3480 Inj potassium chloride 2meq $0.14 J3485 Zidovudine 10mg $1.51 J3486 Ziprasidone mesylate 10mg $10.10 J3489 Zoledronic acid 1mg $12.74 J7030 Normal saline solution infus 1000cc $2.52 J7040 Normal saline solution infus 500ML $1.26 J7042 5% dextrose/normal saline 500ML $1.00 J7050 Normal saline solution infus 250cc $0.63 J7060 5% dextrose/water 500ML $2.48 J7070 D5w infusion 1000cc $4.56 J7120 Ringers lactate infusion 1000cc $2.45 J7189 Factor viia recombinant 1mcg $2.08 J7190 Factor viii 1I.U. $1.08 J7192 Factor viii recombinant 1I.U. $1.30 J7193 Factor IX non-recombinant 1I.U. $1.14 J7194 Factor ix complex 1I.U. $1.43 J7195 Factor IX recombinant 1I.U. $1.50 J7197 Antithrombin iii injection 1I.U. $3.50 J7198 Anti-inhibitor 1I.U. $2.00 J7308 Aminolevulinic acid hcl top 354mg $ J7321 Hyalgan or Supartz, inj PER DOSE $79.91 J7323 Euflexxa, inj PER DOSE $ J7324 Orthovisc, inj PER DOSE $ J7325 Synvisc and Synvisc-One 1mg $11.86 J7500 Azathioprine oral 50mg 50mg $0.89 J7502 Cyclosporine oral 100 mg 100mg $2.45 J7504 Lymphocyte immune globulin 250mg $2, J7507 Tacrolimus oral per 1 MG 1mg $0.58 J7509 Methylprednisolone oral 4mg $0.40 J7511 Antithymocyte globuln rabbit 25mg $ J7515 Cyclosporine oral 25 mg 25mg $0.72 J7516 Cyclosporin parenteral 250mg 250mg $48.89 J7517 Mycophenolate mofetil oral 250mg $1.03 J7520 Sirolimus, oral 1mg $7.23 J7525 Tacrolimus injection 5mg $ J7608 Acetylcysteine inh sol u d 1gm $5.07 J7626 Budesonide inhalation sol mg $2.24 J7631 Cromolyn sodium inh sol u d 10mg $5.58 J7639 Dornase alpha inhal sol u d 1mg $47.79 J7644 Ipratropium brom inh sol u d 1mg $0.21 J7682 Tobramycin inhalation sol 300mg $39.67 J8510 Oral busulfan 2mg $24.13

5 J8520 Capecitabine, oral, 150 mg 150mg $1.15 J8521 Capecitabine, oral, 500 mg 500mg $3.67 J8530 Cyclophosphamide oral 25 MG 25mg $4.54 J8560 Etoposide oral 50 MG 50mg $75.76 J8610 Methotrexate oral 2.5 MG 2.5mg $0.38 J8700 Temozolomide 5mg $0.87 J9000 Doxorubic hcl 10 MG vl chemo 10mg $3.06 J9017 Arsenic trioxide 1mg $46.91 J9031 Bcg live intravesical vac per installation $ J9034 Bendeka inj 1mg $ J9040 Bleomycin sulfate injection 15units $28.77 J9045 Carboplatin injection 50mg $3.25 J9050 Carmus bischl nitro inj 200mg $4, J9060 Cisplatin 10 MG injection 10mg $1.85 J9065 Inj cladribine per 1 MG 1mg $21.88 J9070 Cyclophosphamide 500 MG inj 100mg $37.82 J9100 Cytarabine hcl 100 MG inj 100mg $0.77 J9120 Dactinomycin actinomycin d 0.5mg $1, J9145 Daratumumab inj 10mg $52.30 J9150 Daunorubicin 10mg $48.17 J9171 Docetaxel injection 1mg $1.34 J9176 Elotozumab inj 1mg $6.40 J9178 Inj, epirubicin hcl, 2 mg 2mg $1.19 J9181 Etoposide 10 MG inj 10mg $0.70 J9185 Fludarabine phosphate inj 50mg $79.51 J9190 Fluorouracil injection 500mg $1.79 J9200 Floxuridine injection 500mg $75.59 J9201 Gemcitabine HCl 200mg $5.93 J9202 Goserelin acetate implant 3.6mg $ J9205 Irinotecan liposome inj 1mg $45.65 J9206 Irinotecan injection 20mg $2.86 J9208 Ifosfomide injection 1gm $25.45 J9209 Mesna injection 200mg $2.10 J9211 Idarubicin hcl injection 5mg $32.80 J9214 Interferon alfa-2b inj 1millionunits $34.03 J9217 Leuprolide acetate suspnsion 7.5mg $ J9218 Leuprolide acetate injection 1mg $20.49 J9230 Mechlorethamine hcl inj 10mg $ J9245 Inj melphalan hydrochl 50 MG 50mg $ J9250 Methotrexate sodium inj 5mg $0.25 J9260 Methotrexate sodium inj 50mg $2.52 J9263 Oxaliplatin 0.5mg $0.19 J9268 Pentostatin injection 10mg $2, J9280 Mitomycin 5 MG inj 5mg $ J9293 Mitoxantrone hydrochl / 5 MG 5mg $27.58 J9295 Necitumumab inj 1mg $5.61 J9311 Inj, rixtuximab, hyaluronidase 10mg $46.64 J9312 Inj., rixtuximab, 10mg 10mg $95.40 J9320 Streptozocin injection 1gm $ J9325 talimogene loherparepvec 1million pfu $50.05 J9352 Trabectedin inj 0.1mg $ J9355 Trastuzumab 10mg $107.00

6 J9360 Vinblastine sulfate inj 1mg $3.69 J9370 Vincristine sulfate 1 MG inj 1mg $4.95 J9390 Vinorelbine tartrate/10 mg 20mg $8.27 J9395 Injection, Fulvestrant 25mg $97.49 Q0167 Dronabinol 2.5mg oral 2.5mg $1.17 Q5103 Infliximab biosimiolar inj, inflectra 10mg $57.28 Q5104 Injection, renflexis 10mg $61.90 This information is from the CMS website dated December 12, 2018.

The following are J Code requirements

The following are J Code requirements J Codes 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) A9579 Injection, gadolinium based