`J2250` Inj midazolam hydrochloride

Injection, midazolam hydrochloride, per 1 mg

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

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 22 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 30 units per day (clinical), rationale: Clinical: Data
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J2250

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

J2250 payment limit: $0.167 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J2250 (CMS ASP NDC-HCPCS crosswalk, October 2026)

00409-0001-25 Midazolam, Pfizer Inc: 50 billing units per package (25 VIAL, SINGLE-DOSE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-DOSE)
25021-0655-02 Midazolam, Sagent Pharmaceuticals: 20 billing units per package (10 VIAL in 1 CARTON / 2 mL in 1 VIAL)
25021-0661-10 Midazolam, Sagent Pharmaceuticals: 500 billing units per package (10 VIAL in 1 CARTON / 10 mL in 1 VIAL)
50090-5342-00 Midazolam HCl, A-S Medication Solutions: 500 billing units per package (10 VIAL in 1 BOX / 10 mL in 1 VIAL)
50090-5342-01 Midazolam HCl, A-S Medication Solutions: 50 billing units per package (10 mL in 1 VIAL)
50090-5472-00 Midazolam HCl, A-S Medication Solutions: 100 billing units per package (10 VIAL in 1 BOX / 10 mL in 1 VIAL)
72611-0741-25 Midazolam HCl, Almaject, Inc.: 50 billing units per package
70860-0600-02 Midazolam HCl, Athenex Pharmaceutical Division, LLC: 50 billing units per package
70860-0601-05 Midazolam HCl, Athenex Pharmaceutical Division, LLC: 250 billing units per package
70860-0601-10 Midazolam HCl, Athenex Pharmaceutical Division, LLC: 500 billing units per package
72572-0430-25 Midazolam HCl, Civica, Inc.: 50 billing units per package (25 VIAL in 1 CARTON / 2 mL in 1 VIAL)
72572-0432-10 Midazolam HCl, Civica, Inc.: 50 billing units per package (10 VIAL in 1 CARTON / 5 mL in 1 VIAL)
63323-0411-10 Midazolam HCl, FreseniUS Kabi USA, LLC: 100 billing units per package (10 VIAL in 1 TRAY / 10 mL in 1 VIAL)
63323-0411-12 Midazolam HCl, FreseniUS Kabi USA, LLC: 50 billing units per package (25 VIAL in 1 TRAY / 2 mL in 1 VIAL)
63323-0411-25 Midazolam HCl, FreseniUS Kabi USA, LLC: 125 billing units per package (25 VIAL in 1 TRAY / 5 mL in 1 VIAL)
63323-0412-02 Midazolam HCl, FreseniUS Kabi USA, LLC: 100 billing units per package (10 VIAL in 1 TRAY / 2 mL in 1 VIAL)
63323-0412-10 Midazolam HCl, FreseniUS Kabi USA, LLC: 500 billing units per package (10 VIAL in 1 TRAY / 10 mL in 1 VIAL)
63323-0412-25 Midazolam HCl, FreseniUS Kabi USA, LLC: 125 billing units per package (25 VIAL in 1 TRAY / 1 mL in 1 VIAL)
76045-0001-20 Midazolam HCl, FreseniUS Kabi USA, LLC: 48 billing units per package (24 BLISTER PACK in 1 CARTON / 1 SYRINGE, GLASS in 1 BLISTER PACK / 2 mL in 1 SYRINGE, GLASS)
76045-0211-20 Midazolam HCl, FreseniUS Kabi USA, LLC: 48 billing units per package (24 BLISTER PACK in 1 CARTON / 1 SYRINGE, GLASS in 1 BLISTER PACK / 2 mL in 1 SYRINGE, GLASS)
00404-9780-10 Midazolam HCl, Henry Schein Inc.: 10 billing units per package (1 VIAL in 1 BAG / 10 mL in 1 VIAL)
00404-9801-10 Midazolam HCl, Henry Schein Inc.: 50 billing units per package (1 VIAL in 1 BAG / 10 mL in 1 VIAL)
00404-9912-10 Midazolam HCl, Henry Schein Inc.: 10 billing units per package
00404-9913-05 Midazolam HCl, Henry Schein Inc.: 5 billing units per package (1 VIAL in 1 BAG / 5 mL in 1 VIAL)
00404-9914-10 Midazolam HCl, Henry Schein Inc.: 50 billing units per package
00404-9915-05 Midazolam HCl, Henry Schein Inc.: 25 billing units per package (1 VIAL in 1 BAG / 5 mL in 1 VIAL)
00404-9916-01 Midazolam HCl, Henry Schein Inc.: 5 billing units per package (1 VIAL, SINGLE-DOSE in 1 BAG / 1 mL in 1 VIAL, SINGLE-DOSE)
00404-9916-02 Midazolam HCl, Henry Schein Inc.: 10 billing units per package (1 VIAL, SINGLE-DOSE in 1 BAG / 2 mL in 1 VIAL, SINGLE-DOSE)
23155-0600-41 Midazolam HCl, Heritage Pharmaceuticals Inc.: 50 billing units per package (25 VIAL, SINGLE-DOSE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-DOSE)
23155-0601-41 Midazolam HCl, Heritage Pharmaceuticals Inc.: 250 billing units per package (10 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE)
23155-0601-42 Midazolam HCl, Heritage Pharmaceuticals Inc.: 500 billing units per package (10 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE)
00641-6056-10 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 100 billing units per package (10 VIAL in 1 CARTON / 10 mL in 1 VIAL)
00641-6057-25 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 50 billing units per package (25 VIAL in 1 CARTON / 2 mL in 1 VIAL)
00641-6059-10 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 50 billing units per package (10 VIAL in 1 CARTON / 5 mL in 1 VIAL)
00641-6060-10 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 500 billing units per package (10 VIAL in 1 CARTON / 10 mL in 1 VIAL)
00641-6061-25 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 125 billing units per package (25 VIAL in 1 CARTON / 1 mL in 1 VIAL)
00641-6063-25 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 250 billing units per package (25 VIAL in 1 CARTON / 2 mL in 1 VIAL)
00641-6190-10 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 500 billing units per package (10 VIAL in 1 CARTON / 10 mL in 1 VIAL)
00641-6209-25 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 50 billing units per package (25 VIAL in 1 CARTON / 2 mL in 1 VIAL)
00641-6210-10 Midazolam HCl, Hikma Pharmaceuticals USA Inc.: 50 billing units per package (10 VIAL in 1 CARTON / 5 mL in 1 VIAL)

And 15 more NDCs.

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J2250

Payer coverage policies that name J2250

J2250 appears in 4 coverage policies from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Complex Regional Pain Syndrome (CRPS): Treatments (0447) Ketamine metabolite (2R,6R)-hydroxynorketamine, metformin, topical ketamine, Topical dimethyl sulfoxide, Anakinra, Sarilumab -	not covered	Jul 16, 2026	payer document
Aetna	Epilepsy Surgery (0394)	listed, no stance	Jun 23, 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 (range J2250-J2253)	Jan 27, 2026	payer document

Medicaid fee-for-service

AZ: $0.14 (outpatient_hospital), effective Jul 1, 2026
FL: $22.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $3.63 (practitioner), effective Apr 1, 2026
IN: $0.03 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2018
KY: $0.00 (asc), effective Jan 1, 2026
MS: $0.17 (comprehensive), effective Jul 1, 2026
NE: $0.14 (injectables), effective Jul 1, 2026
OH: $0.17 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $0.14 (healthy_texas_women, Clinic/Group Practice, non-facility), effective Sep 1, 2026
VA: $0.14 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $0.14 (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.

J2250 Inj midazolam hydrochloride