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Physician Administered Drug Program Physician Drug Program Procedure Codes And Rates Effective January 1, 2021 The inclusion of a rate on this table does not guarantee that a service is covered. Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical Policies on the DMA Web Site. Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions, changes, and deletion to this schedule. ****Please note: LARCs, Vaccines, and Clotting Factor rates are priced off of the NDC.**** UPDATED: 6/9/2021 ProcCode NDC Description Facility Non-Facility Effective Date End/Obsolete Date BIOLOGICALS J0129 Abatacept 10 mg, injection (Orencia) $18.73 $18.73 3/1/2020 J0586 AbobotulinumtoxinA, 5 units (Dysport) $7.57 $7.57 3/1/2020 J0178 Aflibercept, 1 mg, injection (Eylea) $982.43 $982.43 3/1/2020 J0202 Alemtuzumab, 1 mg (Lemtrada) $1,831.01 $1,831.01 3/1/2020 J0221 Alglucosidase alfa, 10 mg, injection (Lumizyme) $148.61 $148.61 3/1/2020 J7308 Aminolevulinic acid HCI for topical admin. 20% single unit dosage form (354 mg) (Levulan) (Kerastic $109.98 $109.98 3/1/2020 J7196 Antithrombin (recombinant), 50 IU (ATryn) $105.51 $105.51 3/1/2020 J3590 Asfotase alfa 1 mg (Strensiq) $75.60 $75.60 11/1/2015 J9999 Avelumab injection, 1 mg (Bavencio) $8.12 $8.12 4/1/2017 J0485 Belatacept, 1 mg, injection (Nulojix) $3.81 $3.81 3/1/2020 J0490 Belimumab, 10 mg, injection (Benlysta) $38.49 $38.49 3/1/2020 J0179 Brolucizumab-dbll injection 1 mg (Beovu) $333.46 $333.46 3/1/2020 J0597 C1 Esterase Inhibitor (human), 10 units (Berinert) $27.59 $27.59 3/1/2020 J0598 C1 esterase inhibitor (human), 10 units, injection (Cinryze) $43.64 $43.64 3/1/2020 J0638 Canakinumab, 1 mg vial (Ilaris) $89.35 $89.35 3/1/2020 J0716 Centruriodes Immune F(ab), 120 mg (Anascorp) $3,945.28 $3,945.28 3/1/2020 J3590 Cerliponase alfa injection 1 kit (Brineura) $29,160.00 $29,160.00 6/1/2017 J0717 Certolizumab pegol, 1 mg, injection (Cimzia) $5.45 $5.45 3/1/2020 J0775 Collagenase clostridium histolyticum, 0.01 mg (Xiaflex) $37.59 $37.59 3/1/2020 J0791 Crizanlizumab-tmca injection 5 mg (Adakveo) $122.44 $122.44 7/1/2020 J0897 Denosumab, 1 mg (Xgeva) (Prolia) $14.46 $14.46 3/1/2020 J1300 Eculizumab, 10 mg, injection (Soliris) $176.76 $176.76 3/1/2020 J9358 fam-trastuzumab deruxtecan-nxki for injection 1 mg (Enhertu) $24.19 $24.19 7/1/2020 J1458 Galsulfase injection for intravenous use 1 mg (Naglazyme) $399.53 $399.53 3/1/2020 J1602 Golimumab Hydrochloride 1 mg (Simponi Aria) $25.82 $25.82 3/1/2020 J7178 Human fibrinogen concentrate, 1 mg, injection (RiaSTAP) $0.98 $0.98 3/1/2020 J3590 Human Topical Protein, 1 IU (Recothrom) $0.02 $0.02 1/1/2015 J1744 Icatibant acetate, 1 mg (Firazyr) $152.40 $152.40 3/1/2020 J3590 Idarucizumab injection 2.5 g/50 ml (Praxbind) $1,890.00 $1,890.00 10/1/2015 J3590 Immune Globulin Subcutaneous, 20% solution 100 mg (Cuvitru) $18.14 $18.14 11/1/2016 J0588 IncobotulinumtoxinA, 1 unit (Xeomin) $5.54 $5.54 3/1/2020 J1823 inebilizumab-cdon injection 1 mg (Uplizna) $471.60 $471.60 1/1/2021 J9227 isatuximab-irfc injection 10 mg (Sarclisa) $66.67 $66.67 10/11/2020 J3590 Peanut (Arachis hypogaea) allergen powder-dnfp 1 daily dose (Palforzia) $32.04 $32.04 4/2/2020 Q5108 Pegfilgrastim-jmdb injection 0.5 mg (Fulphila) $387.23 $387.23 3/1/2020 S0145 Peginterferon Alfa-2a, 180 mcg/ml (Pegasys) $337.13 $337.13 3/1/2020 J3590 Peginterferon Alfa-2b, 1 mcg (Sylatron) $3.10 $3.10 1/1/2015 J2507 Pegloticase, 1 mg (Krystexxa) $302.72 $302.72 3/1/2020 S0148 Pegylated interferon alfa-2b, 10 mcg (Peg-Intron) $105.30 $105.30 3/1/2020 J9306 Pertuzumab, 1 mg, injection (Perjeta) $10.84 $10.84 3/1/2020 J2724 Protein C concentrate, intravenous, human, 1 IU, injection (Ceprotin) $12.21 $12.21 3/1/2020 J3590 Prothrombin complex concentrate (Human) 1 IU (Kcentra) $2.04 $2.04 1/1/2015 J2778 Ranibizumab, 0.1 mg, injection (Lucentis) $406.05 $406.05 3/1/2020 J2786 Reslizumab injection 1 mL(Cinqair) $94.69 $94.69 3/1/2020 J2793 Rilonacept, 1 mg injection (Arcalyst) $24.59 $24.59 3/1/2020 J3590 Secukinumab injection 150 mg (Cosentyx) $3,656.66 $3,656.66 4/1/2015 J9999 tafasitamab-cxix for injection 1 mg (Monjuvi) $6.48 $6.48 8/10/2020 3/31/2021 J9349 tafasitamab-cxix for injection 2 mg (Monjuvi) $12.66 $12.66 4/1/2021 J3262 Tocilizumab, 1 mg (Actemra) $3.48 $3.48 3/1/2020 J3357 Ustekinumab Injection for subcutaneous use, 1 mg (Stelara) $112.10 $112.10 3/1/2020 J3358 Ustekinumab injection for intravenous use, 1 mg (Stelara IV) $13.49 $13.49 3/1/2020 J3385 Velaglucerase Alfa, 100 units (VPRIV) $351.28 $351.28 3/1/2020 J9400 Ziv-aflibercept, 1 ml or 25 mg, injection (Zaltrap) $9.96 $9.96 3/1/2020 DRUGS J3490 17 Alpha Hydroxprogesterone Caporoate, Bulk powder, 250 mg (17P) $19.80 $19.80 1/1/2015 J0130 Abciximab, 10mg, injection (ReoPro) $423.96 $423.96 3/1/2020 J1120 Acetazolamide sodium, up to 500 mg, injection (Diamox) $16.71 $16.71 3/1/2020 J0133 Acyclovir, 5 mg, injection (Zovirax) $0.02 $0.02 3/1/2020 J0153 Adenosine injection 1 mg (Adenoscan, Adenocard) $0.93 $0.93 3/1/2020 J9354 Ado-trastuzumab Emtansine, 1 mg, injection (Kadcyla) $32.11 $32.11 3/1/2020 J0180 Agalsidase Beta, 1 mg, injection (Fabrazyme) $129.86 $129.86 3/1/2020 P9047 Albumin (human), 25%, 50 ml, infusion (Albuminar, Albutein, Bluminate), Plasbumin $40.22 $40.22 3/1/2020 P9041 Albumin (human), 5%, 50 ml, infusion (Albiminar, Albutein, Buminate, Plasbumin) $20.10 $20.10 3/1/2020 J9015 Aldesleukin, per single use vial (Proleukin, etc) $769.05 $769.05 3/1/2020 J0215 Alefacept, 0.5 mg, injection (Amevive) $26.71 $26.71 3/1/2020 J0205 Alglucerase, per 10 units, injection (Ceredase) $39.75 $39.75 3/1/2020 J0220 Alglucosidase alfa, 10 mg, injection (Myozyme) $127.47 $127.47 3/1/2020 J0257 Alpha 1 proteinase inhibitor (human), 10 mg (Glassia) $3.86 $3.86 3/1/2020 J0256 Alpha 1-proteinase inhibitor-human, 10mg, injection (Prolastin) (Aralast, Zemaira) $3.67 $3.67 3/1/2020 J2997 Alteplase recombinant, 1 mg, injection (Activase) $32.24 $32.24 3/1/2020 J3490 Amisulpride injection 1 mg (Barhemsys) $9.18 $9.18 8/4/2020 J0207 Amifostine, 500mg, injection (Ethyol) $512.32 $512.32 3/1/2020 J0278 Amikacin sulfate, 100 mg, injection (Amikin) $0.73 $0.73 3/1/2020 J0280 Aminophylline, up to 250mg, injection $0.37 $0.37 3/1/2020 J0300 Amobarbital, up to 125mg, injection (Amytal) $11.98 $11.98 3/1/2020 J0285 Amphotericin B, 50 mg, injection (Amphocin) (Fungizone) $12.00 $12.00 3/1/2020 J0288 Amphotericin B cholesteryl sulfate complex, 10 mg, injection (Amphotec) $12.02 $12.02 3/1/2020 J0287 Amphotericin B lipid complex, 10 mg, injection (Abelcet) $10.48 $10.48 3/1/2020 J0289 Amphotericin B liposome, 10 mg, injection (Ambisome) $17.19 $17.19 3/1/2020 J0290 Ampicillin sodium, 500mg, injection $2.25 $2.25 3/1/2020 J0295 Ampicillin sodium/sulbactam sodium, per 1.5g, injection (Unasyn) $4.41 $4.41 3/1/2020 J7188 Antihemophilic factor (recombinant) porcine sequence 1 IU (Orbizur) $5.85 $5.85 3/1/2020 J7197 Antithrombin III (human), per IU (Throbate III) $1.91 $1.91 3/1/2020 J0400 Aripiprazole, intramuscular, 0.25 mg, injection (Abilify) $0.29 $0.29 3/1/2020 J0401 Aripiprazole, extended release, 1 mg, injection $4.04 $4.04 3/1/2020 J1943 Aripiprazole, lauroxil extended-release injectable suspension 1 mg (Aristada Initio) $3.00 $3.00 3/1/2020 J9017 Arsenic trioxide, 1 mg (Trisenox) $34.55 $34.55 3/1/2020 J9020 Asparaginase, 10,000 units (Elspar) $57.14 $57.14 3/1/2020 J9019 Asparaginase Erwinia Chrysanthemi, 1,000 IUs, injection (Erwinaze) $334.98 $334.98 3/1/2020 J0461 Atropine sulfate, 0.01 mg, injection $0.04 $0.04 3/1/2020 J9025 Azacitidine 1 mg (Vidaza) $4.49 $4.49 3/1/2020 J0456 Azithromycin, 500mg, injection (Zithromax) $18.02 $18.02 3/1/2020 Q0144 Azithromycin dihydrate, oral, capsules/powder, 1 gm (Zithromax, Zithromax Z-Pak) $21.78 $21.78 3/1/2020 J0475 Baclofen, 10mg, injection (Lioresal) $191.26 $191.26 3/1/2020 J0476 Baclofen, 50 mcg for intrathecal trial, injection (Lioresal) $69.91 $69.91 3/1/2020 Q0245 Bamlanivimab and etesevimab, 2100 MG $0.00 $0.00 2/9/2021 J9037 belantamab mafodotin-blmf for injection (Blenrep) 0.5 mg $42.97 $42.97 4/1/2021 J9032 Belinostat 10 mg (Beleodaq) $34.13 $34.13 3/1/2020 J9033 Bendamustine HCl, 1 mg, injection (Treanda) $18.65 $18.65 3/1/2020 J9036 Bendamustine HCl, 1 mg, injection (Belrapzo) $24.66 $24.66 3/1/2020 J0702 Betamethasone acetate and betamethasone sodium phosphate, per 3mg, injection (Celestone) $5.76 $5.76 3/1/2020 (Soluspan) J9035 Bevacizumab, 10 mg, injection (Avastin) $57.57 $57.57 3/1/2020 Q5118 Bevacizumab-bzr injection 10 mg (Zirabev) $69.56 $69.56 3/1/2020 J7351 Bimatoprost implant, for intracameral administration, 1 mcg (Durysta) $210.60 $210.60 10/1/2020 J9040 Bleomycin sulfate, 15 units (Blenoxane) $29.09 $29.09 3/1/2020 J9039 Blinatumomab (Blincyto), 1 mcg $102.98 $102.98 3/1/2020 J9041 Bortezomib, 0.1 mg, inj.
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