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Local Carrier Payment Allowance Limits for Medicare Part B Drugs — Effective July 1, 2015 through September 30, 2015

Revised: 04.04.16

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 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  
90736** Zostavax Per Carrier Medical Director not covered by Part B. Added January 2013
A9606** Radium Ra 223 dichloride (Xofigo) MicroCurie 120.65 Eff:1/1/2015
J0200** Alatrofloxacin mesylate 100 MG Invoice  
J0270** Alprostadil, 1.25 MCG Considered self-administered.  
J0275** Alprostadil Urethral Suppository 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  
J0715** Ceftizoxime sodium / 500 MG 500 MG Invoice  
J1324** Enfuvirtide 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  
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.  
J2950** Promazine HCL (Sparine) 25MG Invoice  
J3030** Sumatriptan Succinate Considered self-administered.  
J3110** Teriparatide injection Considered self-administered.  
J3145 Testosterone Undecanoate(Aveed) 1 MG $1.166 Added January 2015
J3265** Injection torsemide 10 mg/ml 10 MG $4.000  
J3280** Thiethylperazine maleate, inj 10 MG Invoice  
J3310** Perphenazine 5 MG $1.476 Added July 2015
J7130** Hypertonic saline solution 20 CC Invoice  
J7191** Factor viii (porcine) 1 IU Invoice  
J7199** Alprolix - Factor IX Fusion Protein Recombinant 1 Unit $3.210  
J7604** Acetylcystein 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.  
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.  
J8561** Everolimus, 0.25 MG 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  
J9262** Omacetaxine Mepesuccinate(Synribo) 0.01 MG $2.529  
J9270** Plicamycin (mithramycin) inj 2.5 MG Invoice  
J9600** Porfimer Sodium injection 75 MG $20,410.406  
Q0174** Thiethylperazine maleate, 10mg Should be billed to DMAC.  
Q0179** Ondansetron hcl 9 mg 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  
Q2028** Sculptra 0.5 MG Invoice  
Q2034** Agriflu 0.05 ML Invoice  
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  
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  
Q4132** Grafix core 1 SQ CM Invoice  
Q4133** Grafix prime 1 SQ CM Invoice  
Q4137** Amnioexcel or Biodexcel 1 SQ CM Invoice  
Q4138** Biodfence dryflex 1 SQ CM Invoice  
Q4139* Amniomatrix or Biodmatrix 1 CC Invoice  
Q4140** Biodfence 1 SQ CM Invoice  
Q4141** Alloskin ac 1 SQ CM Invoice  
Q4142** Xcm Biologic Tissue Matrix 1 SQ CM Invoice  
Q4143** Repriza 1 SQ CM Invoice  
Q4145** Epifix 1 MG Invoice  
Q4146** Tensix 1 SQ CM Invoice  
Q4147** Architect Extracellular Matrix 1 SQ CM Invoice  
Q4148** Neox 1k 1 SQ CM Invoice  
Q4149** Excellagen 0.1 CC 34.200  
Q4152** Dermapure 1 SQ CM 88.113  
Q9953** Iron Based Magnetic Resonance Contrast Agent 1 ML Invoice Added July 2015
Q9955** Inj perflexane lip micros, ml 1 ML Invoice  

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