Part B vs Part D
J3285 at a glance
Injection, treprostinil, 1 mg
- CMS billing unit
- 1 MG
- Part B payment limit (Q4 2026)
- $54.563 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
- Part B
- Your home infusion pharmacy
- Part B, DME contractor
| 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 | Part B | Part B pays for this drug separately in the hospital outpatient department. |
|
| Home, DME pump | Part B, DME contractor | Part B pays for this drug as a supply for a covered external infusion pump, billed to the DME contractor, when the pump is medically necessary. This needs an enrolled DMEPOS supplier; Part D cannot pay because Part B would. | |
| 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. |
CMS DME policies listing this code: External Infusion Pumps (L33794).
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 | $54.563 | — | — | CMS |
| Home, Part B | $54.563 | — | — | CMS |
| Home, Part D | — | — | — | Does not apply to this case |
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.
CMS's formulary file does not list this drug for Washington plans.
This drug also has a Part B pathway above. The file does not say why it is unlisted.
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.