`J3105` Terbutaline sulfate inj

Injection, terbutaline sulfate, up to 1 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: Clinical: Data
Outpatient hospital: max 4 units per day (clinical), rationale: Clinical: Data
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J3105

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

J3105 payment limit: $1.00 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J3105 (CMS ASP NDC-HCPCS crosswalk, October 2026)

59923-0615-05 Terbutaline Sulfate, Areva Pharmaceuticals: 5 billing units per package
63323-0665-01 Terbutaline Sulfate, FreseniUS Kabi USA, LLC: 25 billing units per package (25 VIAL, SINGLE-USE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-USE)
00404-9962-01 Terbutaline Sulfate, Henry Schein Inc.: 1 billing unit per package (1 VIAL in 1 BAG / 1 mL in 1 VIAL)
00143-9375-10 Terbutaline Sulfate, Hikma Pharmaceuticals USA Inc.: 10 billing units per package (10 VIAL in 1 CARTON / 1 mL in 1 VIAL)
00143-9746-10 Terbutaline Sulfate, Hikma Pharmaceuticals USA Inc.: 10 billing units per package (10 VIAL in 1 CARTON / 1 mL in 1 VIAL)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J3105

Payer coverage policies that name J3105

J3105 appears in 3 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Injectable Medications (0020)	listed, no stance (range J2550-J3520)	Mar 5, 2026	payer document
Aetna	Magnesium Sulfate Injections and Terbutaline Pump for Preterm Labor (0468)	covered if criteria are met	Jul 17, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Acute And Maintenance Tocolysis (L.5.01.584)	covered if criteria are met		payer document

Medicaid fee-for-service

AZ: $2.82 (outpatient_hospital), effective Jul 1, 2026
FL: $2.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $2.96 (practitioner), effective Apr 1, 2026
IN: $1.16 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2021
KS: $1.00 (default), effective Oct 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
MS: $2.96 (comprehensive), effective Jul 1, 2026
NE: $2.82 (injectables), effective Jul 1, 2026
OH: $2.82 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $2.47 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $2.82 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $2.82 (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.

J3105 Terbutaline sulfate inj