`J3250` Trimethobenzamide hcl inj

Injection, trimethobenzamide hcl, up to 200 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 4 units per day (clinical), rationale: Prescribing Information
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J3250

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

J3250 payment limit: $62.418 per 200 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J3250 (CMS ASP NDC-HCPCS crosswalk, October 2026)

42023-0119-25 Tigan, Endo USA, Inc.: 25 billing units per package (25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE)
00404-9964-02 Tigan, Henry Schein Inc.: 1 billing unit per package (1 VIAL, SINGLE-DOSE in 1 BAG / 2 mL in 1 VIAL, SINGLE-DOSE)
51662-1430-01 Tigan, HF Acquisition Co. LLC, DBA HealthFirst: 1 billing unit per package (2 mL in 1 VIAL, SINGLE-DOSE)
51662-1430-03 Tigan, HF Acquisition Co. LLC, DBA HealthFirst: 25 billing units per package (25 POUCH in 1 CASE / 1 VIAL, SINGLE-DOSE in 1 POUCH / 2 mL in 1 VIAL, SINGLE-DOSE)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J3250

2 of 2 payer prior-auth lists that name J3250 require prior authorization or set conditions: UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026

Payer coverage policies that name J3250

J3250 appears in 4 coverage policies from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Anesthetic and Antiemetic Infusion Pumps (0607)	listed, no stance	Sep 9, 2026	payer document
Aetna	Antiemetic Therapy (0724)	listed, no stance	Jul 17, 2026	payer document
Aetna	Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy (0678)	listed, no stance	Oct 7, 2025	payer document
Aetna	Injectable Medications (0020)	listed, no stance (range J2550-J3520)	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

AZ: $62.94 (outpatient_hospital), effective Jul 1, 2026
FL: $2.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $114.44 (practitioner), effective Apr 1, 2026
IN: $58.98 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2026
KS: $62.42 (default), effective Oct 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
LA: $62.94 (professional), effective Jul 1, 2026
MS: $57.22 (comprehensive), effective Jul 1, 2026
NE: $62.93 (injectables), effective Jul 1, 2026
OH: $62.94 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $57.60 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $62.93 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $62.94 (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.

J3250 Trimethobenzamide hcl inj