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April 9, 2008

Local Carrier Payment Allowance Limits for Medicare Part B Drugs

Effective April 1, 2008 through June 30, 2008

Note 1: 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

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.

HCPCS Code Short Description HCPCS Code Dosage Payment Limit Notes
90396** varicella-zoster immune globulin 125 U / 1.25 ML Invoice  
90396** varicella-zoster immune globulin 625 U / 6.25 ML Invoice  
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 Invoice  
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 DME.  
Q9955** Inj perflexane lip micros, ml 1 ML Invoice  

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