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Updated April 7, 2008

Local Carrier Payment Allowance Limits for Medicare Part B Drugs

Effective October 1, 2007 through December 31, 2007

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 Invoice  
J0380** metaraminol bitartrate, inj 10 MG $1.362  
J0390** Chloroquine injection 250 MG Invoice  
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 $13.180  
J1700** Hydrocortisone acetate inj 25 MG $0.360  
J1710** Hydrocortisone sodium ph inj 50 MG Invoice  
J1890** Cephalothin sodium injection 1 G Invoice  
J1960** Levorphanol tartrat 2 MG $3.170  
J2278 KD ** Ziconotide injection 1 MCG $6.775  
J2513** Pentastarch 10% solution 10% Invoice  
J2670** Totazoline hcl injection 25 MG $2.550  
J2940** Somatrem injection Considered self-administered.  
J3110** Teriparatide injection Considered self-administered.  
J3140** Testosterone suspension 50 MG $0.420  
J3150** Testosterone propionate 100 MG $0.840  
J3280** Thiethylperazine maleate, inj 10 MG $5.954  
J7130** Hypertonic saline solution 20 CC Invoice  
J7191** Factor viii (porcine) 1 IU $1.860  
J7622** Beclomethasone inhalation 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.  
J9165** Diethylstilbestrol diphosphate injection 250 MG Invoice  
J9215** Interferon, alfa-n3 250,000 IU $14.336  
J9270** Plicamycin (mithramycin) inj 2.5 MG Invoice  
J9357** Valrubicin 200 MG $369.600  
Q0174** Thiethylperazine maleate10mg Considered self-administered.  
Q0181** Unspecified oral dosage form, FDA approved presription anti-emetic Should be billed to DMERC.  
Q9955** Inj perflexane lip micros, ml 1 ML Invoice  

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