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DME MAC Jurisdiction C

Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees

Effective 04/01/2007 through 06/30/2007

The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.

HCPCS CODE / NDC NUMBER	DESCRIPTION	DOSAGE	FEE
G0333	PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY		$57.000
J0133	INJECTION, ACYCLOVIR	5 MG	$0.470
J0285	AMPHOTERICIN B	50 MG	$10.280
J0287	AMPHOTERICIN B LIPID COMPLEX	10 MG	$21.850
J0288	AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX	10 MG	$15.200
J0289	AMPHOTERICIN B LIPOSOME	10 MG	$35.800
J0882	INJECTION, DARBEPOETIN ALFA, (FOR ESRD ON DIALYSIS)	1 MCG	$3.143
J0886	INJECTION, EPOETIN ALFA, (FOR ESRD ON DIALYSIS)	1000 UNITS	$9.577
J0895	DEFEROXAMINE MESYLATE	500 MG / 5 CC	$15.630
J1170	HYDROMORPHONE	4 MG	$1.490
J1250	DOBUTAMINE HYDROCHLORIDE	250 MG	$4.740
J1265	INJECTION, DOPAMINE HCL	40 MG	$0.620
J1325	EPOPROSTENOL	.5 MG	$12.640
J1455	FOSCARNET SODIUM	1000 MG	$13.070
J1562	INJECTION, IMMUNE GLOBULIN, SUBCUTANEOUS	100 MG	$11.400
J1566	INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER)	500 MG	$25.720
J1567	INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)	500 MG	$30.571
J1570	GANCICLOVIR SODIUM	500 MG	$35.250
J1644AX	INJECTION, HEPARIN SODIUM (FOR ESRD)	1000 UNITS	$0.212
J1815	INSULIN	5 UNITS	$0.252
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP)	50 UNITS	$2.800
J2175	MEPERIDINE HYDROCHLORIDE	100 MG	$0.560
J2260	MILRINONE LACTATE	5 ML	$51.580
J2270	MORPHINE SULFATE	10 MG	$0.710
J2271	MORPHINE SULFATE	100 MG	$11.070
J2275	MORPHINE SULFATE, PRESERVATIVE FREE STERILE SOL	10 MG	$4.390
J2545	PENTAMIDINE FOR AEROSOL INHALER FOR PNEUMOCYSTIS	300 MG	$45.156
J2920	METHYLPREDNISOLONE SODIUM SUCCINATE	40 MG	$2.013
J2930	METHYLPREDNISOLONE SODIUM SUCCINATE	125 MG	$2.514
J3010	FENTANYL CITRATE	2 ML	$0.700
J3285	INJECTION, TREPROSTINIL	1 MG	$61.750
J7500	AZATHIOPRINE, ORAL	50 MG	$0.182
J7501	AZATHIOPRINE, PARENTERAL	100 MG	$48.442
J7502	CYCLOSPORINE, ORAL	100 MG	$3.599
J7504	LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL	250 MG	$317.184
J7505	MUROMONAB-CD3 PARENTERAL	5 MG	$895.149
J7506	PREDNISONE, ORAL	5 MG	$0.192
J7507	TACROLIMUS, ORAL	1 MG	$3.662
J7509	METHYLPREDNISOLONE, ORAL	4 MG	$0.078
J7510	PREDNISOLONE, ORAL	5 MG	$0.040
J7511	LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL	25 MG	$327.752
J7513	DACLIZUMAB, PARENTERAL	25 MG	$299.863
J7515	CYCLOSPORINE, ORAL	25 MG	$0.949
J7516	CYCLOSPORINE, PARENTERAL	250 MG	$19.680
J7517	MYCOPHENOLATE MOFETIL, ORAL	250 MG	$2.624
J7518	MYCOPHENOLIC ACID, ORAL	180 MG	$2.267
J7520	SIROLIMUS, ORAL	1 MG	$7.222
J7525	TACROLIMUS, PARENTERAL	5 MG	$140.439
J7607	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	0.5 MG	TBD*
J7608KO	ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 GM	$2.630
J7609KO	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7609KP	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7609KQ	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7610	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7611	ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.071
J7612	LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM	0.5 MG	$0.922
J7613KO	ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	$0.081
J7614KO	LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	$1.535
J7615KO	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	TBD*
J7615KP	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	TBD*
J7615KQ	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	TBD*
J7620	ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME	1 UNIT	$1.148
J7622KO	BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7622KP	BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7622KQ	BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7624KO	BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7624KP	BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7624KQ	BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7626KO	BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	$4.564
J7627KO	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	TBD*
J7627KP	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	TBD*
J7627KQ	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	TBD*
J7628	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7629KO	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7629KP	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7629KQ	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7631KO	CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	10 MG	$0.070
J7634	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	0.25 MG	TBD*
J7635	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.266
J7636KO	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.338
J7636KP	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.338
J7636KQ	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.266
J7637	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.124
J7638KO	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7638KP	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7638KQ	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7639KO	DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$19.873
J7641KO	FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7641KP	FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7641KQ	FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7642	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$1.525
J7643KO	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$1.705
J7643KP	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$1.705
J7643KQ	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$1.525
J7644KO	IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.170
J7645KO	IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7645KP	IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7645KQ	IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7647	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7650KO	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7650KP	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7650KQ	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7657	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7660KO	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7660KP	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7660KQ	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7667	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATED FORM	10 MG	TBD*
J7669KO	METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	10 MG	$0.254
J7670KO	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7670KP	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7670KQ	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7680	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7681KO	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7681KP	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7681KQ	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7682KO	TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME	300 MG	$57.280
J7683	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.121
J7684KO	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.157
J7684KP	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.157
J7684KQ	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.121
J7685KO	TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	300 MG	TBD*
J7685KP	TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	300 MG	TBD*
J76855KQ	TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	300 MG	TBD*
J8501	APREPITANT, ORAL	5 MG	$5.067
J8520	CAPECITABINE, ORAL	150 MG	$3.974
J8521	CAPECITABINE, ORAL	500 MG	$13.242
J8530	CYCLOPHOSPHAMIDE; ORAL	25 MG	$0.975
J8540	DEXAMETHASONE, ORAL	0.25 MG	$0.249
J8610	METHOTREXATE; ORAL	2.5 MG	$0.260
J8650	NABILONE, ORAL	1 MG	$16.000
J9000	DOXORUBICIN HCL	10 MG	$12.540
J9001	DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULTAIONS	10 MG	$393.480
J9040	BLEOMYCIN SULFATE	15 UNITS	$289.370
J9065	CLADRIBINE	1 MG	$61.720
J9070	CYCLOPHOSPHAMIDE	100 MG	$5.730
J9080	CYCLOPHOSPHAMIDE	200 MG	$10.890
J9100	CYTARABINE	100 MG	$8.190
J9110	CYTARABINE	500 MG	$8.550
J9150	DAUNORUBICIN HYDROCHLORIDE	10 MG	$74.230
J9181	ETOPOSIDE	10 MG	$1.710
J9182	ETOPOSIDE	100 MG	$17.100
J9190	FLUOROURACIL	500 MG	$2.070
J9200	FLOXURIDINE	500 MG	$136.800
J9208	IFOSFAMIDE	1 GM	$150.380
J9263	OXALIPLATIN	0.5 MG	$9.446
J9265	PACLITAXEL	30 MG	$162.170
J9280	MITOMYCIN	5 MG	$127.400
J9290	MITOMYCIN	20 MG	$323.200
J9293	MITOXANTRONE HYDROCHLORIDE	5 MG	$359.350
J9350	TOPOTECAN	4 MG	$798.650
J9355	TRASTUZUMAB	10 MG	$58.130
J9360	VINBLASTINE SULFATE	1 MG	$4.100
J9370	VINCRISTINE SULFATE	1 MG	$33.980
J9375	VINCRISTINE SULFATE	2 MG	$67.960
J9380	VINCRISTINE SULFATE	5 MG	$169.910
J9390	VINORELBINE TARTRATE	10 MG	$109.000
Q0163	DIPHENHYDRAMINE HYDROCHLORIDE, ORAL	50 MG	$0.031
Q0164	PROCHLORPERAZINE MALEATE, ORAL	5MG	$0.040
Q0165	PROCHLORPERAZINE MALEATE, ORAL	10 MG	$0.099
Q0166	GRANISETRON HYDROCHLORIDE	1 MG	$44.867
Q0167	DRONABINOL, ORAL	2.5 MG	$4.951
Q0168	DRONABINOL, ORAL	5 MG	$10.115
Q0169	PROMETHAZINE HYDROCHLORIDE, ORAL	12.5 MG	TBD*
Q0170	PROMETHAZINE HYDROCHLORIDE, ORAL	25 MG	$0.365
Q0171	CHLORPROMAZINE HYDROCHLORIDE, ORAL	10 MG	$0.026
Q0172	CHLORPROMAZINE HYDROCHLORIDE, ORAL	25 MG	$0.058
Q0173	TRIMETHOBENZAMIDE HYDROCHLORIDE, ORAL	250 MG	$0.324
Q0174	THIETHYLPERAZINE MALEATE, ORAL	10 MG	TBD*
Q0175	PERPHENAZINE, ORAL	4 MG	$0.191
Q0176	PERPHENAZINE, ORAL	8 MG	$0.201
Q0177	HYDROXYZINE PAMOATE, ORAL	25 MG	$0.059
Q0178	HYDROXYZINE PAMOATE, ORAL	50 MG	$0.060
Q0179	ONDANSETRON HYDROCHLORIDE, ORAL	8 MG	$36.550
Q0180	DOLASETRON MESYLATE, ORAL	100 MG	$47.519
Q0510	PHARMACY SUPPLY FEE FOR INITIAL IMMUNOSUPPRESSIVE DRUG(S), FIRST MONTH FOLLOWING TRANSPLANT		$50.000
Q0511	PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR THE FIRST PRESCRIPTION IN A 30-DAY PERIOD		$24.000
Q0512	PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR A SUBSEQUENT PRESCRIPTION IN A 30-DAY PERIOD		$16.000
Q0513	PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 30 DAYS		$33.000
Q0514	PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 90 DAYS		$66.000
Q4080	ILOPROST, INHALATION SOLUTION, ADMINISTERED THROUGH DME	20 MCG	$34.238
Q4081	INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)		$0.958
00173-0713-25	BUSULFAN, ORAL	2 MG	$2.136
00004-1100-13	CAPECITABINE, ORAL	150 MG	$3.974
00004-1100-20	CAPECITABINE, ORAL	150 MG	$3.974
00004-1100-22	CAPECITABINE, ORAL	150 MG	$3.974
00004-1100-51	CAPECITABINE, ORAL	150 MG	$3.974
54868-4143-00	CAPECITABINE, ORAL	150 MG	$3.974
54868-4143-02	CAPECITABINE, ORAL	150 MG	$3.974
54868-4143-03	CAPECITABINE, ORAL	150 MG	$3.974
00004-1101-13	CAPECITABINE, ORAL	500 MG	$13.242
00004-1101-16	CAPECITABINE, ORAL	500 MG	$13.242
00004-1101-50	CAPECITABINE, ORAL	500 MG	$13.242
00004-1101-51	CAPECITABINE, ORAL	500 MG	$13.242
54569-5717-00	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-00	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-01	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-02	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-03	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-04	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-05	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-06	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-07	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-08	CAPECITABINE, ORAL	500 MG	$13.242
54868-5260-09	CAPECITABINE, ORAL	500 MG	$13.242
00015-0504-01	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.975
00054-4129-25	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.975
00054-8089-25	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.975
54569-5712-00	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.975
54868-5218-00	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.975
54868-5218-01	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.975
54868-5218-02	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.975
00015-0503-01	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.950
00015-0503-02	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.950
00054-4130-25	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.950
00054-8130-25	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.950
54569-5713-00	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.950
54868-5005-00	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.950
54868-5005-01	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.950
00015-3091-45	ETOPOSIDE, ORAL	50 MG	$29.604
00378-3266-94	ETOPOSIDE, ORAL	50 MG	$29.604
51079-0965-05	ETOPOSIDE, ORAL	50 MG	$29.604
54569-5718-00	ETOPOSIDE, ORAL	50 MG	$29.604
54868-5355-00	ETOPOSIDE, ORAL	50 MG	$29.604
54868-5355-02	ETOPOSIDE, ORAL	50 MG	$29.604
00081-0045-35	MELPHALAN, ORAL	2 MG	$4.336
00173-0045-35	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-00	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-01	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-02	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-03	MELPHALAN, ORAL	2 MG	$4.336
59572-0302-50	MELPHALAN, ORAL	2 MG	$4.336
00005-4507-04	METHOTREXATE, ORAL	2.5 MG	$0.260
00005-4507-05	METHOTREXATE, ORAL	2.5 MG	$0.260
00005-4507-07	METHOTREXATE, ORAL	2.5 MG	$0.260
00005-4507-09	METHOTREXATE, ORAL	2.5 MG	$0.260
00005-4507-23	METHOTREXATE, ORAL	2.5 MG	$0.260
00005-4507-91	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-4550-15	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-4550-25	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-8550-03	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-8550-05	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-8550-06	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-8550-07	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-8550-10	METHOTREXATE, ORAL	2.5 MG	$0.260
00054-8550-25	METHOTREXATE, ORAL	2.5 MG	$0.260
00182-1539-01	METHOTREXATE, ORAL	2.5 MG	$0.260
00182-1539-95	METHOTREXATE, ORAL	2.5 MG	$0.260
00364-2499-01	METHOTREXATE, ORAL	2.5 MG	$0.260
00364-2499-36	METHOTREXATE, ORAL	2.5 MG	$0.260
00378-0014-01	METHOTREXATE, ORAL	2.5 MG	$0.260
00378-0014-50	METHOTREXATE, ORAL	2.5 MG	$0.260
00536-3998-01	METHOTREXATE, ORAL	2.5 MG	$0.260
00536-3998-36	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0572-02	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0572-35	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0572-45	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0572-46	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0572-47	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0572-48	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0572-49	METHOTREXATE, ORAL	2.5 MG	$0.260
00603-4499-21	METHOTREXATE, ORAL	2.5 MG	$0.260
00677-1610-01	METHOTREXATE, ORAL	2.5 MG	$0.260
00781-1076-01	METHOTREXATE, ORAL	2.5 MG	$0.260
00781-1076-36	METHOTREXATE, ORAL	2.5 MG	$0.260
00904-1749-60	METHOTREXATE, ORAL	2.5 MG	$0.260
00904-1749-73	METHOTREXATE, ORAL	2.5 MG	$0.260
49999-0380-24	METHOTREXATE, ORAL	2.5 MG	$0.260
51079-0670-05	METHOTREXATE, ORAL	2.5 MG	$0.260
51285-0509-02	METHOTREXATE, ORAL	2.5 MG	$0.260
51432-0522-03	METHOTREXATE, ORAL	2.5 MG	$0.260
52959-0244-00	METHOTREXATE, ORAL	2.5 MG	$0.260
54569-1818-08	METHOTREXATE, ORAL	2.5 MG	$0.260
54868-3826-03	METHOTREXATE, ORAL	2.5 MG	$0.260
54868-3826-04	METHOTREXATE, ORAL	2.5 MG	$0.260
54868-3826-05	METHOTREXATE, ORAL	2.5 MG	$0.260
54868-3826-06	METHOTREXATE, ORAL	2.5 MG	$0.260
54868-3826-07	METHOTREXATE, ORAL	2.5 MG	$0.260
55289-0924-30	METHOTREXATE, ORAL	2.5 MG	$0.260
58469-3998-30	METHOTREXATE, ORAL	2.5 MG	$0.260
59911-5874-01	METHOTREXATE, ORAL	2.5 MG	$0.260
62701-0940-36	METHOTREXATE, ORAL	2.5 MG	$0.260
62701-0940-99	METHOTREXATE, ORAL	2.5 MG	$0.260
63629-1472-01	METHOTREXATE, ORAL	2.5 MG	$0.260
67253-0320-10	METHOTREXATE, ORAL	2.5 MG	$0.260
67253-0580-42	METHOTREXATE, ORAL	2.5 MG	$0.260
67253-0580-43	METHOTREXATE, ORAL	2.5 MG	$0.260
67253-0580-44	METHOTREXATE, ORAL	2.5 MG	$0.260
67253-0580-45	METHOTREXATE, ORAL	2.5 MG	$0.260
67253-0580-46	METHOTREXATE, ORAL	2.5 MG	$0.260
68115-0632-00	METHOTREXATE, ORAL	2.5 MG	$0.260
00555-0927-01	METHOTREXATE, ORAL	5 MG	$0.520
51285-0366-01	METHOTREXATE, ORAL	5 MG	$0.520
00555-0928-01	METHOTREXATE, ORAL	7.5 MG	$0.780
51285-0367-01	METHOTREXATE, ORAL	7.5 MG	$0.780
00555-0929-01	METHOTREXATE, ORAL	10 MG	$1.040
51285-0368-01	METHOTREXATE, ORAL	10 MG	$1.040
00555-0945-01	METHOTREXATE, ORAL	15 MG	$1.560
51285-0369-01	METHOTREXATE, ORAL	15 MG	$1.560
00085-1248-01	TEMOZOLOMIDE, ORAL	5 MG	$7.409
00085-1248-02	TEMOZOLOMIDE, ORAL	5 MG	$7.409
00085-1248-03	TEMOZOLOMIDE, ORAL	5 MG	$7.409
54569-5836-00	TEMOZOLOMIDE, ORAL	5 MG	$7.409
54569-5837-00	TEMOZOLOMIDE, ORAL	5 MG	$7.409
54868-5348-00	TEMOZOLOMIDE, ORAL	5 MG	$7.409
54868-5348-01	TEMOZOLOMIDE, ORAL	5 MG	$7.409
00085-1244-01	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1244-02	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1425-01	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1425-02	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1430-01	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1430-02	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1519-01	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1519-02	TEMOZOLOMIDE, ORAL	20 MG	$29.636
54569-5838-00	TEMOZOLOMIDE, ORAL	20 MG	$29.636
54569-5839-00	TEMOZOLOMIDE, ORAL	20 MG	$29.636
54868-4142-00	TEMOZOLOMIDE, ORAL	20 MG	$29.636
54868-4142-02	TEMOZOLOMIDE, ORAL	20 MG	$29.636
54868-4142-03	TEMOZOLOMIDE, ORAL	20 MG	$29.636
54868-4142-04	TEMOZOLOMIDE, ORAL	20 MG	$29.636
54868-4142-06	TEMOZOLOMIDE, ORAL	20 MG	$29.636
00085-1259-01	TEMOZOLOMIDE, ORAL	100 MG	$148.180
00085-1259-02	TEMOZOLOMIDE, ORAL	100 MG	$148.180
00085-1366-01	TEMOZOLOMIDE, ORAL	100 MG	$148.180
00085-1366-02	TEMOZOLOMIDE, ORAL	100 MG	$148.180
54569-5842-00	TEMOZOLOMIDE, ORAL	100 MG	$148.180
54569-5843-00	TEMOZOLOMIDE, ORAL	100 MG	$148.180
54868-5350-01	TEMOZOLOMIDE, ORAL	100 MG	$148.180
54868-5350-02	TEMOZOLOMIDE, ORAL	100 MG	$148.180
54868-5350-03	TEMOZOLOMIDE, ORAL	100 MG	$148.180
54868-5350-04	TEMOZOLOMIDE, ORAL	100 MG	$148.180
00085-1252-01	TEMOZOLOMIDE, ORAL	250 MG	$370.450
00085-1252-02	TEMOZOLOMIDE, ORAL	250 MG	$370.450
00085-1417-01	TEMOZOLOMIDE, ORAL	250 MG	$370.450
54569-5844-00	TEMOZOLOMIDE, ORAL	250 MG	$370.450
54569-5845-00	TEMOZOLOMIDE, ORAL	250 MG	$370.450
54868-5354-00	TEMOZOLOMIDE, ORAL	250 MG	$370.450

*To Be Developed (TBD) is used for HCPCS codes where there was no fee on the ASP file and we were unable to locate published WAC pricing, therefore we will develop for an invoice on this drug.