License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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Local Carrier Payment Allowance Limits for Medicare Part B Drugs — Effective January 1, 2013 through March 31, 2013

Revised 08.01.14

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.html

Note 2: Payment allowance limits subject to the ASP methodology are based on 2Q12 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.
90736**	Zostavax	Per Carrier Medical Director not covered by Part B.		Added January 2013
J0135**	Adalimumab, 20 MG	Considered self-administered.
J0200**	Alatrofloxacin mesylate	100 MG	Invoice
J0270**	Alprostadil, 1.25 MCG	Considered self-administered.
J0275**	Alprostadil Urethral Suppository	Considered self-administered.
J0364**	Apomorphine / Hydrochloride	Considered self-administered.
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
J0630**	Calcitonin Salmon	Considered self-administered.
J0715**	Ceftizoxime sodium / 500 MG	500 MG	Invoice
J1060**	Testosterone cypionate 1 ML	1 ML	Invoice
J1324**	Enfuvirtide	Considered self-administered.
J1438**	Etanercept	Considered self-administered.
J1590**	Gatifloxacin injection	Considered self-administered.
J1595**	Injection glatiramer acetate	Considered self-administered.
J1675**	Histrelin Acetate	Considered self-administered.
J1680**	fibrinogen concentrate human	100 MG	$103.550
J1700**	Hydrocortisone acetate inj	25 MG	$0.360
J1710**	Hydrocortisone sodium ph inj	50 MG	Invoice
J1725**	Hydroxyprogesterone Caporate	1 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
J2170**	Mecasermin	Considered self-administered.
J2265**	Minocycline Hydrochloride	Considered self-administered.
J2278KD**	Ziconotide injection	1 MCG	Invoice
J2320**	Nandrolone decanoate 50 MG	50 MG	$4.452
J2354**	Octreotide Acetate	Considered self-administered.
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	Considered self-administered.
J3030**	Sumatriptan Succinate	Considered self-administered.
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
J7180**	Factor XIII	1 I.U.	Invoice
J7191**	Factor viii (porcine)	1 IU	Invoice
J7500**	Azathioprine oral 50 mg	Should be billed to DMAC
J7502**	Cyclosporine oral 100 mg	Should be billed to DMAC
J7506**	Prednisone oral	Should be billed to DMAC
J7507**	Tacrolimus oral per 1 MG	Should be billed to DMAC
J7509**	Methylprednisolone oral	Should be billed to DMAC
J7510**	Prednisolone oral per 5 mg	Should be billed to DMAC
J7515**	Cyclosporine oral 25 mg	Should be billed to DMAC
J7517**	Mycophenolate mofetil oral	Should be billed to DMAC
J7518**	Mycophenolic acid	Should be billed to DMAC
J7520**	Sirolimus, oral	Should be billed to DMAC
J7604**	Acetylcystein	Considered part of procedure in physician's office.
J7605**	Arformoterol non-comp unit	Considered part of procedure in physician's office.
J7606**	Formoterol fumarate, inh	Considered part of procedure in physician's office.
J7608**	Acetylcystein non-comp unit	Considered part of procedure in physician's office.
J7611**	Albuterol non-comp con	Considered part of procedure in physician's office.
J7612**	Levalbuterol non-comp con	Considered part of procedure in physician's office.
J7613**	Albuterol non-comp unit	Considered part of procedure in physician's office.
J7614**	Levalbuterol non-comp unit	Considered part of procedure in physician's office.
J7620**	Albuterol ipratrop non-comp	Considered part of procedure in physician's office.
J7622**	Beclomethasone inhalation sol	Considered part of procedure in physician's office.
J7624**	Betamethasone inhalation sol	Considered part of procedure in physician's office.
J7626**	Budesonide non-comp unit	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.
J7631**	Cromolyn sodium non-comp unit	Considered part of procedure in physician's office.
J7633**	Budesonide concentrated sol	Considered part of procedure in physician's office.
J7639**	Dornase alfa non-comp unit	Considered part of procedure in physician's office.
J7641**	Flunisolide, inhalation sol	Considered part of procedure in physician's office.
J7644**	Ipratropium bromide non-comp	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.
J7665**	Mannitol inh sol	Considered part of procedure in physician's office.
J7668**	Metaproterenol inh sol con	Considered part of procedure in physician's office.
J7669**	Metaproterenol non-comp unit	Considered part of procedure in physician's office.
J7674**	Methacholine chloride, neb	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.
J7682**	Tobramycin non-comp unit	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.
J7686**	Treprostinil non-comp unit	Considered part of procedure in physician's office.
J8501**	Oral aprepitant	Should be billed to DMAC.
J8510**	Oral busulfan	Should be billed to DMAC.
J8520**	Capecitabine, oral 150 mg	Should be billed to DMAC.
J8521**	Capecitabine, oral 500 mg	Should be billed to DMAC.
J8530**	Cyclophosphamide oral 25 MG	Should be billed to DMAC.
J8540**	Oral dexamethasone	Should be billed to DMAC.
J8560**	Etoposide oral 50 MG	Should be billed to DMAC.
J8561**	Everolimus, 0.25 MG	Should be billed to DMAC.
J8562**	Oral fludarabine phosphate	Should be billed to DMAC.
J8600**	Melphalan oral 2 MG	Should be billed to DMAC.
J8610**	Methotrexate oral 2.5 MG	Should be billed to DMAC.
J8700**	Temozolomide	Should be billed to DMAC.
J8705**	Topotecan oral	Should be billed to DMAC.
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
J9218**	Leuprolide Acetate	Considered self-administered.
J9270**	Plicamycin (mithramycin) inj	2.5 MG	Invoice
J9600**	Porfimer Sodium injection	75 MG	$20,410.406
Q0163**	Diphenhydramine HCI 50 mg	Should be billed to DMAC.
Q0164**	Prochlorperazine maleate 5 mg	Should be billed to DMAC.
Q0165**	Prochlorperazine maleate 10 mg	Should be billed to DMAC.
Q0166**	Granisetron hcl 1 mg oral	Should be billed to DMAC.
Q0167**	Dronabinol 2.5 mg oral	Should be billed to DMAC.
Q0168**	Dronabinol 5 mg oral	Should be billed to DMAC.
Q0169**	Promethazine HCI 12.5 mg oral	Should be billed to DMAC.
Q0170**	Promethazine HCI 25 mg oral	Should be billed to DMAC.
Q0174**	Thiethylperazine maleate, 10mg	Should be billed to DMAC.
Q0179**	Ondansetron hcl 9 mg oral	Should be billed to DMAC.
Q0180**	Dolasetron mesylate oral	Should be billed to DMAC.
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
Q2034**	Agriflu	0.05 ML	Invoice
Q2039**	Not Otherwise Classified flu vacc, 3 yrs & >, im	0.5 ML	$12.375
Q4074**	Iloprost non-comp unit dose	Considered part of procedure in physician's office.
Q4118**	Matristem Micromatrix	1 MG	$2.433
Q4119**	Matristem Micromatrix	1 SQ CM	$2.470
Q4122**	Dermacell	1 SQ CM	Invoice
Q4124**	Oasis Ultra Tri-Layer Wound Matrix	1 SQ CM	$11.400
Q4125**	Arthroflex	1 SQ CM	Invoice
Q4126**	Memoderm	1 SQ CM	Invoice
Q4127**	Talymed	1 SQ CM	Invoice
Q4128**	Flex HD or Allopatch HD	1 SQ CM	Invoice
Q4129**	Unite Biomatrix	1 SQ CM	Invoice
Q4130**	Strattice TM	1 SQ CM	Invoice
Q9955**	Inj perflexane lip micros, ml	1 ML	Invoice
Q9970**	Ferric Carboxymaltose ( Injectafer )	1 MG	$1.092

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Local Carrier Payment Allowance Limits for Medicare Part B Drugs — Effective January 1, 2013 through March 31, 2013

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