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July 1, 2011 - Revised: 01.03.12

Local Carrier Payment Allowance Limits for Medicare Part B Drugs

Effective July 1, 2011 through September 30, 2011

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 2: Payment allowance limits subject to the ASP methodology are based on 1Q11 ASP data.

Note 3: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 4: ** - Carrier-priced

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  
90661** Flu vaccine, derived from cell cultures, subunit Per Carrier Medical Director not covered by Part B.  
J0200** Alatrofloxacin mesylate 100 MG Invoice  
J0380** metaraminol bitartrate, inj 10 MG Invoice  
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 Invoice  
J0715** Ceftizoxime sodium / 500 MG 500 MG Invoice  
J1060** Testosterone cypionate 1 ML 1 ML Invoice  
J1590** Gatifloxacin injection Considered self-administered.  
J1595** Injection glatiramer acetate 20 MG $ 3,962.374  
J1680** fibrinogen concentrate human 100 MG $ 103.550  
J1700** Hydrocortisone acetate inj 25 MG $ 0.360  
J1710** Hydrocortisone sodium ph inj 50 MG Invoice  
J1830** Interferon beta-1b / .25 MG Not covered by carrier.  
J1890** Cephalothin sodium injection 1 G Invoice  
J1960** Levorphanol tartrate 2 MG $ 3.765  
J1990** Chlordiazepoxide injection 100 MG Invoice  
J2278 KD ** Ziconotide injection 1 MCG Invoice  
J2320** Nandrolone decanoate 50 MG 50 MG $ 4.452  
J2513** Pentastarch 10% solution 10% Invoice  
J2650** Prednisolone acetate 1 ML $ 0.342  
J2670** Tolazoline hcl injection 25 MG Invoice  
J2940** Somatrem injection Considered self-administered.  
J2941** Somatropin injection Not covered by carrier.  
J3110** Teriparatide injection Considered self-administered.  
J3140** Testosterone suspension 50 MG $ 0.420  
J3150** Testosterone propionate 100 MG $ 0.798  
J3265** Injection torsemide 10 mg/ml 10 MG $ 4.000  
J3280** Thiethylperazine maleate, inj 10 MG Invoice  
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.  
J8562** Oral fludarabine phosphate Considered self-administered.  
J8600** Melphalan oral 2 MG Considered self-administered.  
J9165** Diethylstilbestrol diphosphate injection 250 MG Invoice  
J9213** Interferon alfa-2a inj 3 MIL UNITS Invoice  
J9215** Interferon, alfa-n3 250,000 IU $ 23.834  
J9270** Plicamycin (mithramycin) inj 2.5 MG Invoice  
Q0174** Thiethylperazine maleate, 10mg Considered self-administered.  
Q0181** Unspecified oral dosage form, FDA approved presription anti-emetic Should be billed to DMAC.  
Q2026** Radiesse injection 0.1 ML Invoice  
Q2027** Sculptra injection 0.1 ML Invoice  
Q2035** Afluria vacc, 3 yrs & >, im 0.5 ML $ 12.398  
Q2039** Not Otherwise Classified flu vacc, 3 yrs & >, im 0.5 ML $ 12.375  
Q4118** Matristem Micromatrix 1 MG $ 2.433  
Q4119** Matristem Micromatrix 1 SQ CM $ 2.470  
Q9955** Inj perflexane lip micros, ml 1 ML Invoice  

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