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Updated April 7, 2008

Local Carrier Payment Allowance Limits for Medicare Part B Drugs

Effective July 1, 2006 through September 30, 2006

Note 1: ** - Carrier-priced

Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor processing the claim.

Note 3: The complete ASP Payment Allowance Limits list can be accessed at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.htmlExternal Website

HCPCS Code Short Description HCPCS Code Dosage Payment Limit Notes
90396** varicella-zoster immune globulin 125 U / 1.25 ML $145.749  
90396** varicella-zoster immune globulin 625 U / 6.25 ML $716.994  
J0200** Alatrofloxacin mesylate 100 MG $16.992  
J0380** metaraminol bitartrate, inj 10 MG $1.362  
J0390** Chloroquine injection 250 MG $17.270  
J0395** Arbutamine HCl injection 1 MG Invoice  
J0520** Bethanechol chloride inject Oral drug considered part of procedure in physician's office.  
J0620** calcium glycerophosphate/calcium lactate 10 ML $11.847  
J0880** Darbepoetin alfa injection 5 MCG $15.061  
J1563** IV immune globulin 1 GM $56.718  
J1564** Immune globulin 10 mg 10 MG $0.567  
J1700** Hydrocortisone acetate inj 25 MG $0.342  
J1710** Hydrocortisone sodium ph inj 50 MG $4.685  
J1750** Iron dextran 50 MG $11.344  
J1890** Cephalothin sodium injection 1 G $8.640  
J1960** levorphanol tartrate 2 MG $3.604  
J2278 KD ** Ziconotide injection 1 MCG $7.074  
J2324** Nesiritide 0.25 MG $74.737  
J2670** Totazoline hcl injection 25 MG $3.440  
J2940** Somatrem injection Considered self-administered.  
J3110** Teriparatide injection Considered self-administered.  
J3140** Testosterone suspension 50 MG $0.657  
J3150** Testosterone propionate 100 MG $0.840  
J3280** Thiethylperazine maleate, inj 10 MG $5.656  
J7051** Sterile saline/water 5 CC $0.039  
J7130** Hypertonic saline solution 20 CC $1.345  
J7191** Factor VIII (porcine) 1 IU $1.860  
J7616** Albuterol compound solution Considered part of procedure in physician's office.  
J7622** Beclomethasone inhalatn sol Considered part of procedure in physician's office.  
J7624** Betamethasone inhalation sol Considered part of procedure in physician's office.  
J7628** Bitolterol mes inhal sol con Considered part of procedure in physician's office.  
J7629** Bitolterol mes inh sol u d Considered part of procedure in physician's office.  
J7633** Budesonide concentrated sol Considered part of procedure in physician's office.  
J7641** Flunisolide, inhalation sol Considered part of procedure in physician's office.  
J7648** Isoetharine hcl inh sol con Considered part of procedure in physician's office.  
J7649** Isoetharine hcl inh sol u d Considered part of procedure in physician's office.  
J7658** Isoproterenol hcl inh sol con Considered part of procedure in physician's office.  
J7659** Isoproterenol hcl inh sol ud Considered part of procedure in physician's office.  
J7668** Metaproterenol inh sol con Considered part of procedure in physician's office.  
J7680** Terbutaline so4 inh sol con Considered part of procedure in physician's office.  
J7681** Terbutaline so4 inh sol u d Considered part of procedure in physician's office.  
J7683** Triamcinolone inh sol con Considered part of procedure in physician's office.  
J7684** Triamcinolone inh sol u d Considered part of procedure in physician's office.  
J8600** Melphalan oral 2 MG Considered self-administered.  
J9093** Cyclophosphamide, lyophilized 100 MG $5.194  
J9094** Cyclophosphamide, lyophilized 200 MG $10.388  
J9095** Cyclophosphamide, lyophilized 500 MG $25.970  
J9096** Cyclophosphamide, lyophilized 1 GM $51.940  
J9097** Cyclophosphamide, lyophilized 2 GM $103.880  
J9165** Diethylstilbestrol injection 250 MG $12.135  
J9215** Interferon, alfa-n3 250,000 IU $9.118  
J9270** Plicamycin (mithramycin) inj 2.5 MG $78.989  
J9357** Valrubicin 200 MG $391.776  
Q0136** Non esrd epoetin alpha inj 1000 UNITS $9.219  
Q0137** Darbepoetin alfa, non-esrd 1 MCG $3.012  
Q0174** Thiethylperazine maleate10mg Considered self-administered.  
Q0181** Unspecified oral dosage form, FDA approved presription anti-emetic Should be billed to DMERC.  
Q0187** Factor viia recombinant 1.2 MG $1,227.513  
Q2002** Elliotts b solution per ml 1 ML $3.464  
Q2003** Aprotinin, 10,000 kiu 10000 KIU $2.310  
Q2005** Corticorelin ovine triflutat 1 EA $375.993  
Q2006** Digoxin immune fab (ovine) 1 EA $546.925  
Q2007** Ethanolamine oleate 100 mg 100 MG $79.354  
Q2008** Fomepizole, 15 mg 15 MG $11.875  
Q2011** Hemin, per 1 mg 1 MG $6.769  
Q2012** Pegademase bovine, 25 iu 25 IU $166.067  
Q2013** Pentastarch 10% solution 10% $12.722  
Q2014** Sermorelin acetate, 0.5 mg 0.5 MG $8.813  
Q2018** Urofollitropin, 75 iu 75 IU $48.448  
Q2019** Basiliximab 20 MG $1,420.758  
Q2021** Lepirudin 50 MG $146.919  
Q2022** VonWillebrandFactrCmplxperIU 1 IU $0.873  
Q4054** Darbepoetin alfa, esrd use 1 MCG $3.012  
Q9955** Inj perflexane lip micros, ml 1 ML Invoice  

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