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Utah rates for HCPCS Q0177

Hydroxyzine pamoate, 25 mg, oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.98 / $13.49 / $37.15
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $60.26
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $0.49 / $0.65
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.11 / $0.12 / $0.27
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.79 / $0.98 / $1.07
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13