`J3376` Inj vancomycin (hikma) 10mg

Injection, vancomycin hcl (hikma), not therapeutically equivalent to j3373, 10 mg

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

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 600 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 600 units per day (clinical), rationale: CMS Policy
DME supplier: max 600 units per day (clinical), rationale: CMS Policy

Medicare pricing for J3376

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

J3376 payment limit: $0.016 per 10 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J3376 (CMS ASP NDC-HCPCS crosswalk, October 2026)

00143-9161-10 Vancomycin HCl, Hikma Pharmaceuticals USA Inc.: 500 billing units per package (10 VIAL in 1 PACKAGE / 513 mg in 1 VIAL)
00143-9161-25 Vancomycin HCl, Hikma Pharmaceuticals USA Inc.: 1250 billing units per package (25 VIAL in 1 PACKAGE / 513 mg in 1 VIAL)
00143-9162-10 Vancomycin HCl, Hikma Pharmaceuticals USA Inc.: 1000 billing units per package (10 VIAL in 1 PACKAGE / 1025 mg in 1 VIAL)
00143-9163-01 Vancomycin HCl, Hikma Pharmaceuticals USA Inc.: 500 billing units per package (1 VIAL, PHARMACY BULK PACKAGE in 1 CARTON / 5.13 g in 1 VIAL, PHARMACY BULK PACKAGE)
00143-9164-01 Vancomycin HCl, Hikma Pharmaceuticals USA Inc.: 1000 billing units per package (1 VIAL, PHARMACY BULK PACKAGE in 1 CARTON / 10.25 g in 1 VIAL, PHARMACY BULK PACKAGE)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J3376

Payer coverage policies that name J3376

J3376 appears in 1 coverage policy from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Injectable Medications (0020)	listed, no stance (range J2550-J3520)	Mar 5, 2026	payer document

Medicaid fee-for-service

AZ: $0.02 (outpatient_hospital), effective Jul 1, 2026
FL: $200.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $0.01 (practitioner), effective Apr 1, 2026
IN: $0.03 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KS: $0.01 (default, Exempt Physician), effective Jul 1, 2026
LA: $0.02 (professional), effective Jul 1, 2026
MS: $0.01 (comprehensive), effective Jul 1, 2026
NE: $0.01 (injectables), effective Jul 1, 2026
OH: $0.01 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.02 (physician, non-facility), effective Jul 1, 2026
TX: $0.02 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Jan 1, 2026
VA: $0.01 (medical), effective Jan 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $0.02 (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.

J3376 Inj vancomycin (hikma) 10mg