`J1120` Acetazolamid sodium injectio

Injection, acetazolamide sodium, up to 500 mg

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

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 2 units per day (clinical), rationale: Prescribing Information
Outpatient hospital: max 2 units per day (clinical), rationale: Prescribing Information
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J1120

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

J1120 payment limit: $23.951 per 500 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J1120 (CMS ASP NDC-HCPCS crosswalk, October 2026)

25021-0839-20 Acetazolamide, Sagent Pharmaceuticals: 1 billing unit per package (1 VIAL in 1 CARTON / 5 mL in 1 VIAL)
23155-0313-31 Acetazolamide Sodium, Heritage Pharmaceuticals Inc.: 1 billing unit per package (5 mL in 1 VIAL, GLASS)
23155-0831-31 Acetazolamide Sodium, Heritage Pharmaceuticals Inc.: 1 billing unit per package (1 VIAL, GLASS in 1 CARTON / 5 mL in 1 VIAL, GLASS)
00143-9006-01 Acetazolamide Sodium, Hikma Pharmaceuticals USA Inc.: 1 billing unit per package (1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)
00143-9503-01 Acetazolamide Sodium, Hikma Pharmaceuticals USA Inc.: 1 billing unit per package (1 VIAL in 1 BOX, UNIT-DOSE / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)
67457-0853-50 Acetazolamide Sodium, Mylan Institutional LLC: 1 billing unit per package (1 VIAL in 1 CARTON / 5 mL in 1 VIAL)
39822-0190-01 Acetazolamide Sodium, XGen Pharmaceuticals DJB, Inc.: 1 billing unit per package (1 VIAL, GLASS in 1 CARTON / 5 mL in 1 VIAL, GLASS)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J1120

Payer coverage policies that name J1120

J1120 appears in 4 coverage policies from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Functional Electrical Stimulation and Neuromuscular Electrical Stimulation (0677)	listed, no stance	Sep 10, 2026	payer document
Aetna	Glaucoma Surgery (0484)	listed, no stance	Jul 14, 2026	payer document
Aetna	Injectable Medications (0020)	listed, no stance (range J0278-J2543)	Mar 5, 2026	payer document
Aetna	Vasectomy Procedures and Chronic Scrotal Content Pain (0027)	listed, no stance	Jan 27, 2026	payer document

Medicaid fee-for-service

AZ: $28.13 (outpatient_hospital), effective Jul 1, 2026
IL: $48.72 (practitioner), effective Apr 1, 2026
IN: $20.53 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2024
KS: $23.95 (default), effective Oct 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
MS: $24.36 (comprehensive), effective Jul 1, 2026
NE: $28.12 (injectables), effective Jul 1, 2026
OH: $24.36 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $25.59 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $28.12 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $28.13 (professional_administered_drugs), 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.

J1120 Acetazolamid sodium injectio