`J0290` Ampicillin 500 mg inj

Injection, ampicillin sodium, 500 mg

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 24 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 24 units per day (clinical), rationale: Clinical: Data
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J0290

Medicare Part B drug payment limit (ASP, October 2026)

J0290 payment limit: $0.619 per 500 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J0290 (CMS ASP NDC-HCPCS crosswalk, October 2026)

50090-4552-00 Ampicillin Sodium, A-S Medication Solutions: 4 billing units per package
72485-0421-10 Ampicillin Sodium, Armas Pharmaceuticals Inc.: 20 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
72485-0422-10 Ampicillin Sodium, Armas Pharmaceuticals Inc.: 40 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
72485-0423-10 Ampicillin Sodium, Armas Pharmaceuticals Inc.: 20 billing units per package (1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON)
70860-0112-15 Ampicillin Sodium, Athenex Pharmaceutical Division, LLC: 5 billing units per package
70860-0113-15 Ampicillin Sodium, Athenex Pharmaceutical Division, LLC: 10 billing units per package
70860-0114-15 Ampicillin Sodium, Athenex Pharmaceutical Division, LLC: 20 billing units per package
70860-0115-26 Ampicillin Sodium, Athenex Pharmaceutical Division, LLC: 40 billing units per package
70860-0118-99 Ampicillin Sodium, Athenex Pharmaceutical Division, LLC: 20 billing units per package (1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE)
83634-0100-99 Ampicillin Sodium, Avenacy Inc.: 20 billing units per package (1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE)
72572-0016-10 Ampicillin Sodium, Civica, Inc.: 20 billing units per package (10 VIAL, GLASS in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS)
72572-0017-10 Ampicillin Sodium, Civica, Inc.: 40 billing units per package (10 VIAL, GLASS in 1 CARTON / 2 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS)
72572-0093-10 Ampicillin Sodium, Civica, Inc.: 20 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
72572-0094-10 Ampicillin Sodium, Civica, Inc.: 40 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
55150-0113-10 Ampicillin Sodium, Eugia US LLC: 20 billing units per package (10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
55150-0114-20 Ampicillin Sodium, Eugia US LLC: 40 billing units per package (10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
55150-0115-99 Ampicillin Sodium, Eugia US LLC: 200 billing units per package (10 VIAL, PHARMACY BULK PACKAGE in 1 BOX / 100 mL in 1 VIAL, PHARMACY BULK PACKAGE)
65219-0014-10 Ampicillin Sodium, FreseniUS Kabi USA, LLC: 5 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
65219-0016-10 Ampicillin Sodium, FreseniUS Kabi USA, LLC: 10 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
65219-0018-10 Ampicillin Sodium, FreseniUS Kabi USA, LLC: 20 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
65219-0020-23 Ampicillin Sodium, FreseniUS Kabi USA, LLC: 40 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
00404-9803-99 Ampicillin Sodium, Henry Schein Inc.: 2 billing units per package
00404-9816-99 Ampicillin Sodium, Henry Schein Inc.: 2 billing units per package
00404-9818-99 Ampicillin Sodium, Henry Schein Inc.: 4 billing units per package (1 VIAL in 1 BAG / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
23155-0915-41 Ampicillin Sodium, Heritage Pharmaceuticals Inc.: 10 billing units per package (10 VIAL in 1 PACKAGE / 500 mg in 1 VIAL)
23155-0916-41 Ampicillin Sodium, Heritage Pharmaceuticals Inc.: 20 billing units per package (10 VIAL in 1 PACKAGE / 1 g in 1 VIAL)
23155-0917-41 Ampicillin Sodium, Heritage Pharmaceuticals Inc.: 40 billing units per package (10 VIAL in 1 PACKAGE / 2 g in 1 VIAL)
51662-1560-03 Ampicillin Sodium, HF Acquisition Co. LLC, DBA HealthFirst: 40 billing units per package (10 POUCH in 1 CASE / 1 VIAL in 1 POUCH / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
51662-1595-03 Ampicillin Sodium, HF Acquisition Co. LLC, DBA HealthFirst: 5 billing units per package (10 POUCH in 1 CASE / 1 VIAL in 1 POUCH / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
72603-0221-10 Ampicillin Sodium, Northstar RxLLC: 10 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
72603-0363-10 Ampicillin Sodium, Northstar RxLLC: 20 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
72603-0454-10 Ampicillin Sodium, Northstar RxLLC: 40 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)
72603-0578-01 Ampicillin Sodium, Northstar RxLLC: 20 billing units per package (1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE)
66794-0220-41 Ampicillin Sodium, Piramal Critical Care Inc: 5 billing units per package
66794-0222-41 Ampicillin Sodium, Piramal Critical Care Inc: 20 billing units per package
66794-0223-41 Ampicillin Sodium, Piramal Critical Care Inc: 40 billing units per package
66794-0224-15 Ampicillin Sodium, Piramal Critical Care Inc: 20 billing units per package
25021-0134-10 Ampicillin Sodium, Sagent Pharmaceuticals: 5 billing units per package
25021-0135-10 Ampicillin Sodium, Sagent Pharmaceuticals: 10 billing units per package
25021-0136-10 Ampicillin Sodium, Sagent Pharmaceuticals: 20 billing units per package (10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL)

And 24 more NDCs.

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J0290

1 of 1 payer prior-auth lists that name J0290 require prior authorization or set conditions: Rocky Mountain Health Plans.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025

Payer coverage policies that name J0290

J0290 appears in 1 coverage policy from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Injectable Medications (0020)	listed, no stance (range J0278-J2543)	Mar 5, 2026	payer document

Recent prior-auth changes

Nov 1, 2025: PA removed, UnitedHealthcare
Apr 1, 2025: conditions changed, UnitedHealthcare
Mar 1, 2025: conditions changed, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in WA.

AZ: $0.61 (outpatient_hospital), effective Jul 1, 2026
FL: $24.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $0.64 (practitioner), effective Apr 1, 2026
IN: $0.52 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2021
KS: $0.62 (default), effective Oct 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
LA: $0.61 (professional), effective Jul 1, 2026
MS: $0.64 (comprehensive), effective Jul 1, 2026
NE: $0.61 (injectables), effective Jul 1, 2026
OH: $0.61 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $0.59 (healthy_texas_women, Clinic/Group Practice, non-facility), effective Sep 1, 2026
VA: $0.61 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $0.61 (kidneycenters), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

J0290 Ampicillin 500 mg inj