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DME MAC Jurisdiction C

Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees

Effective 07/01/2007 through 09/30/2007

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	$3.048
J0886	INJECTION, EPOETIN ALFA, (FOR ESRD ON DIALYSIS)	1000 UNITS	$9.104
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	$26.828
J1570	GANCICLOVIR SODIUM	500 MG	$35.250
J1644AX	INJECTION, HEPARIN SODIUM (FOR ESRD)	1000 UNITS	$0.210
J1815	INSULIN	5 UNITS	$0.251
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	$46.121
J2920	METHYLPREDNISOLONE SODIUM SUCCINATE	40 MG	$1.992
J2930	METHYLPREDNISOLONE SODIUM SUCCINATE	125 MG	$3.650
J3010	FENTANYL CITRATE	2 ML	$0.700
J3285	INJECTION, TREPROSTINIL	1 MG	$61.750
J7500	AZATHIOPRINE, ORAL	50 MG	$0.192
J7501	AZATHIOPRINE, PARENTERAL	100 MG	$50.392
J7502	CYCLOSPORINE, ORAL	100 MG	$3.536
J7504	LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL	250 MG	$343.347
J7505	MUROMONAB-CD3 PARENTERAL	5 MG	$942.340
J7506	PREDNISONE, ORAL	5 MG	$0.159
J7507	TACROLIMUS, ORAL	1 MG	$3.738
J7509	METHYLPREDNISOLONE, ORAL	4 MG	$0.086
J7510	PREDNISOLONE, ORAL	5 MG	$0.029
J7511	LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL	25 MG	$336.009
J7513	DACLIZUMAB, PARENTERAL	25 MG	$316.686
J7515	CYCLOSPORINE, ORAL	25 MG	$0.916
J7516	CYCLOSPORINE, PARENTERAL	250 MG	$20.151
J7517	MYCOPHENOLATE MOFETIL, ORAL	250 MG	$2.629
J7518	MYCOPHENOLIC ACID, ORAL	180 MG	$2.269
J7520	SIROLIMUS, ORAL	1 MG	$7.563
J7525	TACROLIMUS, PARENTERAL	5 MG	$140.545
J7608KO	ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 GM	$2.341
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	$1.105
J7626KO	BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	$4.744
J7631KO	CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	10 MG	$0.069
J7639KO	DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$19.865
J7644KO	IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.189
J7669KO	METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	10 MG	$0.270
J7682KO	TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME	300 MG	$60.739
J8501	APREPITANT, ORAL	5 MG	$5.059
J8520	CAPECITABINE, ORAL	150 MG	$4.215
J8521	CAPECITABINE, ORAL	500 MG	$14.009
J8530	CYCLOPHOSPHAMIDE; ORAL	25 MG	$0.984
J8540	DEXAMETHASONE, ORAL	0.25 MG	$0.252
J8610	METHOTREXATE; ORAL	2.5 MG	$0.251
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	$0.042
Q0165	PROCHLORPERAZINE MALEATE, ORAL	10 MG	$0.052
Q0166	GRANISETRON HYDROCHLORIDE	1 MG	$48.655
Q0167	DRONABINOL, ORAL	2.5 MG	$5.098
Q0168	DRONABINOL, ORAL	5 MG	$10.830
Q0169	PROMETHAZINE HYDROCHLORIDE, ORAL	12.5 MG	$0.463
Q0170	PROMETHAZINE HYDROCHLORIDE, ORAL	25 MG	$0.290
Q0171	CHLORPROMAZINE HYDROCHLORIDE, ORAL	10 MG	$0.023
Q0172	CHLORPROMAZINE HYDROCHLORIDE, ORAL	25 MG	$0.055
Q0173	TRIMETHOBENZAMIDE HYDROCHLORIDE, ORAL	250 MG	$0.325
Q0174	THIETHYLPERAZINE MALEATE, ORAL	10 MG	TBD*
Q0175	PERPHENAZINE, ORAL	4 MG	$0.205
Q0176	PERPHENAZINE, ORAL	8 MG	$0.203
Q0177	HYDROXYZINE PAMOATE, ORAL	25 MG	$0.052
Q0178	HYDROXYZINE PAMOATE, ORAL	50 MG	$0.059
Q0179	ONDANSETRON HYDROCHLORIDE, ORAL	8 MG	$25.029
Q0180	DOLASETRON MESYLATE, ORAL	100 MG	$47.108
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	ILOPORST, INHALATION SOLUTION, ADMINISTERED THROUGH DME	20 MCG	$37.991
Q4081	INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)		$0.910
Q4087	INJECTION, IMMUNE GLOBULIN (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)	500 MG	$33.483
Q4088	INJECTION, IMMUNE GLOBULIN (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)	500 MG	$31.197
Q4089	INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN),(RHOPHYLAC), INTRAMUSCULAR OR INTRAVENOUS	100 IU	$5.333
Q4091	INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)	500 MG	$32.614
Q4092	INJECTION, IMMUNE GLOBULIN (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)	500 MG	$31.860
Q4093	ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM 1 MG (ALBUTEROL) OR PER 0.5 MG	1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)	$0.127
Q4094KO	ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)	$0.525
00173-0713-25	BUSULFAN, ORAL	2 MG	$2.276
00004-1100-13	CAPECITABINE, ORAL	150 MG	$4.215
00004-1100-20	CAPECITABINE, ORAL	150 MG	$4.215
00004-1100-22	CAPECITABINE, ORAL	150 MG	$4.215
00004-1100-51	CAPECITABINE, ORAL	150 MG	$4.215
54868-4143-00	CAPECITABINE, ORAL	150 MG	$4.215
54868-4143-02	CAPECITABINE, ORAL	150 MG	$4.215
54868-4143-03	CAPECITABINE, ORAL	150 MG	$4.215
00004-1101-13	CAPECITABINE, ORAL	500 MG	$14.009
00004-1101-16	CAPECITABINE, ORAL	500 MG	$14.009
00004-1101-50	CAPECITABINE, ORAL	500 MG	$14.009
00004-1101-51	CAPECITABINE, ORAL	500 MG	$14.009
54569-5717-00	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-00	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-01	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-02	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-03	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-04	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-05	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-06	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-07	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-08	CAPECITABINE, ORAL	500 MG	$14.009
54868-5260-09	CAPECITABINE, ORAL	500 MG	$14.009
00015-0504-01	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.984
00054-4129-25	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.984
00054-8089-25	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.984
54569-5712-00	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.984
54868-5218-00	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.984
54868-5218-01	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.984
54868-5218-02	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.984
00015-0503-01	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.968
00015-0503-02	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.968
00054-4130-25	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.968
00054-8130-25	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.968
54569-5713-00	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.968
54868-5005-00	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.968
54868-5005-01	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.968
00015-3091-45	ETOPOSIDE, ORAL	50 MG	$29.633
00378-3266-94	ETOPOSIDE, ORAL	50 MG	$29.633
51079-0965-05	ETOPOSIDE, ORAL	50 MG	$29.633
54569-5718-00	ETOPOSIDE, ORAL	50 MG	$29.633
54868-5355-00	ETOPOSIDE, ORAL	50 MG	$29.633
54868-5355-02	ETOPOSIDE, ORAL	50 MG	$29.633
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	$0.251
00005-4507-05	METHOTREXATE, ORAL	2.5 MG	$0.251
00005-4507-07	METHOTREXATE, ORAL	2.5 MG	$0.251
00005-4507-09	METHOTREXATE, ORAL	2.5 MG	$0.251
00005-4507-23	METHOTREXATE, ORAL	2.5 MG	$0.251
00005-4507-91	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-4550-15	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-4550-25	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-8550-03	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-8550-05	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-8550-06	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-8550-07	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-8550-10	METHOTREXATE, ORAL	2.5 MG	$0.251
00054-8550-25	METHOTREXATE, ORAL	2.5 MG	$0.251
00182-1539-01	METHOTREXATE, ORAL	2.5 MG	$0.251
00182-1539-95	METHOTREXATE, ORAL	2.5 MG	$0.251
00364-2499-01	METHOTREXATE, ORAL	2.5 MG	$0.251
00364-2499-36	METHOTREXATE, ORAL	2.5 MG	$0.251
00378-0014-01	METHOTREXATE, ORAL	2.5 MG	$0.251
00378-0014-50	METHOTREXATE, ORAL	2.5 MG	$0.251
00536-3998-01	METHOTREXATE, ORAL	2.5 MG	$0.251
00536-3998-36	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0572-02	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0572-35	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0572-45	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0572-46	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0572-47	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0572-48	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0572-49	METHOTREXATE, ORAL	2.5 MG	$0.251
00603-4499-21	METHOTREXATE, ORAL	2.5 MG	$0.251
00677-1610-01	METHOTREXATE, ORAL	2.5 MG	$0.251
00781-1076-01	METHOTREXATE, ORAL	2.5 MG	$0.251
00781-1076-36	METHOTREXATE, ORAL	2.5 MG	$0.251
00904-1749-60	METHOTREXATE, ORAL	2.5 MG	$0.251
00904-1749-73	METHOTREXATE, ORAL	2.5 MG	$0.251
49999-0380-24	METHOTREXATE, ORAL	2.5 MG	$0.251
51079-0670-05	METHOTREXATE, ORAL	2.5 MG	$0.251
51285-0509-02	METHOTREXATE, ORAL	2.5 MG	$0.251
51432-0522-03	METHOTREXATE, ORAL	2.5 MG	$0.251
52959-0244-00	METHOTREXATE, ORAL	2.5 MG	$0.251
54569-1818-08	METHOTREXATE, ORAL	2.5 MG	$0.251
54868-3826-03	METHOTREXATE, ORAL	2.5 MG	$0.251
54868-3826-04	METHOTREXATE, ORAL	2.5 MG	$0.251
54868-3826-05	METHOTREXATE, ORAL	2.5 MG	$0.251
54868-3826-06	METHOTREXATE, ORAL	2.5 MG	$0.251
54868-3826-07	METHOTREXATE, ORAL	2.5 MG	$0.251
55289-0924-30	METHOTREXATE, ORAL	2.5 MG	$0.251
58469-3998-30	METHOTREXATE, ORAL	2.5 MG	$0.251
59911-5874-01	METHOTREXATE, ORAL	2.5 MG	$0.251
62701-0940-36	METHOTREXATE, ORAL	2.5 MG	$0.251
62701-0940-99	METHOTREXATE, ORAL	2.5 MG	$0.251
63629-1472-01	METHOTREXATE, ORAL	2.5 MG	$0.251
67253-0320-10	METHOTREXATE, ORAL	2.5 MG	$0.251
67253-0580-42	METHOTREXATE, ORAL	2.5 MG	$0.251
67253-0580-43	METHOTREXATE, ORAL	2.5 MG	$0.251
67253-0580-44	METHOTREXATE, ORAL	2.5 MG	$0.251
67253-0580-45	METHOTREXATE, ORAL	2.5 MG	$0.251
67253-0580-46	METHOTREXATE, ORAL	2.5 MG	$0.251
68115-0632-00	METHOTREXATE, ORAL	2.5 MG	$0.251
00555-0927-01	METHOTREXATE, ORAL	5 MG	$0.502
51285-0366-01	METHOTREXATE, ORAL	5 MG	$0.502
00555-0928-01	METHOTREXATE, ORAL	7.5 MG	$0.753
51285-0367-01	METHOTREXATE, ORAL	7.5 MG	$0.753
00555-0929-01	METHOTREXATE, ORAL	10 MG	$1.004
51285-0368-01	METHOTREXATE, ORAL	10 MG	$1.004
00555-0945-01	METHOTREXATE, ORAL	15 MG	$1.506
51285-0369-01	METHOTREXATE, ORAL	15 MG	$1.506
00085-1248-01	TEMOZOLOMIDE, ORAL	5 MG	$7.405
00085-1248-02	TEMOZOLOMIDE, ORAL	5 MG	$7.405
00085-1248-03	TEMOZOLOMIDE, ORAL	5 MG	$7.405
54569-5836-00	TEMOZOLOMIDE, ORAL	5 MG	$7.405
54569-5837-00	TEMOZOLOMIDE, ORAL	5 MG	$7.405
54868-5348-00	TEMOZOLOMIDE, ORAL	5 MG	$7.405
54868-5348-01	TEMOZOLOMIDE, ORAL	5 MG	$7.405
00085-1244-01	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1244-02	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1425-01	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1425-02	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1430-01	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1430-02	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1519-01	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1519-02	TEMOZOLOMIDE, ORAL	20 MG	$29.620
54569-5838-00	TEMOZOLOMIDE, ORAL	20 MG	$29.620
54569-5839-00	TEMOZOLOMIDE, ORAL	20 MG	$29.620
54868-4142-00	TEMOZOLOMIDE, ORAL	20 MG	$29.620
54868-4142-02	TEMOZOLOMIDE, ORAL	20 MG	$29.620
54868-4142-03	TEMOZOLOMIDE, ORAL	20 MG	$29.620
54868-4142-04	TEMOZOLOMIDE, ORAL	20 MG	$29.620
54868-4142-06	TEMOZOLOMIDE, ORAL	20 MG	$29.620
00085-1259-01	TEMOZOLOMIDE, ORAL	100 MG	$148.100
00085-1259-02	TEMOZOLOMIDE, ORAL	100 MG	$148.100
00085-1366-01	TEMOZOLOMIDE, ORAL	100 MG	$148.100
00085-1366-02	TEMOZOLOMIDE, ORAL	100 MG	$148.100
54569-5842-00	TEMOZOLOMIDE, ORAL	100 MG	$148.100
54569-5843-00	TEMOZOLOMIDE, ORAL	100 MG	$148.100
54868-5350-01	TEMOZOLOMIDE, ORAL	100 MG	$148.100
54868-5350-02	TEMOZOLOMIDE, ORAL	100 MG	$148.100
54868-5350-03	TEMOZOLOMIDE, ORAL	100 MG	$148.100
54868-5350-04	TEMOZOLOMIDE, ORAL	100 MG	$148.100
00085-1252-01	TEMOZOLOMIDE, ORAL	250 MG	$370.250
00085-1252-02	TEMOZOLOMIDE, ORAL	250 MG	$370.250
00085-1417-01	TEMOZOLOMIDE, ORAL	250 MG	$370.250
54569-5844-00	TEMOZOLOMIDE, ORAL	250 MG	$370.250
54569-5845-00	TEMOZOLOMIDE, ORAL	250 MG	$370.250
54868-5354-00	TEMOZOLOMIDE, ORAL	250 MG	$370.250

*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.