Part B vs Part D
J0490 at a glance
Injection, belimumab, 10 mg
- CMS billing unit
- 10 MG
- Part B payment limit (Q4 2026)
- $58.333 per unit
- OPPS status (Q4 2026)
- K Paid separately (non-pass-through drug or biological)
This case
Questions appear only when they change the answer.
Other situations
Who pays, by setting
Your two sites first, then every setting.
- Your HOPD
- Needs a check
- Your home infusion pharmacy
- Part D
| Setting | Who pays | Why | Source |
|---|---|---|---|
| Inpatient Part A stay | Part A bundle | The hospital's Part A payment includes the drug, with no separate drug payment. If Part A days are used up or the stay is not covered, Part B or Part D may apply. Clotting factors are paid separately. | |
| SNF Part A stay | Part A bundle | The facility's Part A payment includes the drug, under consolidated billing. Certain high-intensity chemotherapy drugs are billed separately under Part B. If the stay is not covered by Part A, the long-term care row applies. | |
| Hospice | Hospice benefit | The hospice benefit covers drugs for symptom control or pain relief related to the terminal illness. Drugs for an unrelated condition follow the other rows. | |
| HOPD | Needs a check | Choose a route: on Noridian's list the subcutaneous form is excluded and the IV form is not. |
|
| Home, DME pump | Does not apply | Not on Medicare's external infusion pump drug list, so the next row applies. |
|
| Home, no pump | Part D | Part D pays for the drug only. Home infusion supplies and nursing are never covered under Part D. Part D does not cover some uses whatever the setting, such as weight loss, fertility, and cosmetic use. | |
| Long-term care, not a Part A stay | Part D | Part D pays here, even for drugs given by a pump or nebulizer, because a long-term care facility is not a home for the DME benefit. Part D does not cover some uses whatever the setting, such as weight loss, fertility, and cosmetic use. |
Dollars for the lawful pathways
Part B applies 2% sequestration to Medicare's share. The Part D benchmark is a retail average, not a home infusion contract rate.
| Pathway | Per HCPCS unit | Per dose | Per month | Source |
|---|---|---|---|---|
| HOPD, Part B | — | — | — | Does not apply to this case |
| Home, Part B | — | — | — | Does not apply to this case |
| Home, Part D | — | — | — | No authoritative public data was located for this field. |
CMS's median plan cost is $1,304.951 per NDC unit. These units don't convert cleanly, so no dollar comparison is shown.
Part D pays no supplies or nursing. For administration and nursing, use Site of care.
Washington Part D plans
From CMS's quarterly formulary file. A plan's own rules decide; check its formulary before billing.
125 of 125 Washington plans list this drug: 10 of 10 PDPs and 115 of 115 MA-PDs.
- Tier 1 to 5
- Prior authorization on 106 plans
- Step therapy on 0 plans
- Quantity limit on 57 plans
Matched by ndc, product, rxcui.
How this is decided
- Each row follows CMS rules from the statute and manuals. Noridian JF's self-administered drug list decides for Washington; other contractors' lists are counted but do not change the answer.
- Medicare Advantage: the benefit answer is the same, but plan rules and rates differ.
- Being on a CMS list does not by itself meet coverage criteria. Check the LCD, the diagnosis, and the patient's plan before billing.
Guidance only, not a coverage determination.
Disclaimer. This application provides informational coding and reimbursement reference data. It does not constitute legal, clinical, coding, or billing advice. Codes, payment amounts, payer rules, and coverage policies can change. Verify all information with current CMS publications, the applicable payer, and your organization’s compliance policies before submitting a claim. CodeRx is not affiliated with or endorsed by CMS, FDA, Medicare, or any payer.