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Part B Not Otherwise Classified Drug Fee Schedule

Revised 04/23/2004

Name of Drug and Exact Dosage Given in Block 19 (paper) or Narrative Field (EMC)

** Carrier Priced Changes In Bold

DRUG NAME	DOSAGE	Current PAR	Current NONPAR	*Price Change
**Advate-rAHF-PFM (anti-hemophilic factor VIII) J7199 "Effective 05/01/04 file under code J7192".	Per IU	1.58	1.50	A
**Alfentanil HCL (Alfenta)	500 mcg/5 ml	2.29	2.18
** Alimta (see pemetrexed)
Allopurinol Sodium (Aloprim) ICD-9's 274.9 or 790.6 plus the ICD-9 for the neoplasm. Need name of chemotherapy agent causing the elevation of uric acid and a statement as to why patient can not tolerate oral form of the drug.	500 mg/SDV	425.00	403.75
Amikacin Sulfate (Amikin)	500 mg	5.10	4.85
Amino Acid	500 ml	21.11	20.05
Amino Acid	1000 ml	35.19	33.43
**Arginine HCL (R-Gene 10) A4641 Diagnostic Agent		Invoice	Invoice
**Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg/ml	0.80	0.76
** Avastin (see bevacizumab)
Aztreonam (Azactam)	500 mg	9.89	9.40
** Bacitracin (Bacim)	50,000 U	10.17	9.66
** Bevacizumab (Avastin) J9999 Covered for colorectal cancer ICD-9 codes 153.0 through 154.8	100mg	653.13	620.47	A
** Bortezomib (Velcade) Covered for patients with relapsed Multiple Myeloma (203.00)	3.5mg/ SDV	1,039.68	987.70
Bretylium Tosylate (Bretylol)	500 mg	19.07	18.12
** Brevibloc (See Esmolol HCL)
Bumetanide (Bumex)	1 mg	1.43	1.36
Bupivacaine Hcl, 0..25%, 2 ml (Considered Part of Procedure)	2 ml	0.14	0.13
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)	2 ml	0.26	0.25
** Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	10 ml	1.95	1.85
** Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	10 ml	2.21	2.10
** Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400-64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	10 ml	2.48	2.36
** Calcium Chloride	100 mg/ml	0.14	0.13
** Cefamanadole Nafate (Mandol)	1 gm	8.61	8.18
Cefepime Hydrochloride	1 mg	0.02	0.02
** Cefoperazone Sodium (Cefobid)	1 gram	16.38	15.56
Cefotetan Disodium (Cefotan)	1 gram	9.49	9.02
** Cetuximab (Erbitux) Covered indications 153.0 through 154.8	100mg/50ml SDV	547.20	519.84	A
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.03 or 995.2	150 mg	1.27	1.21
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.03 or 995.2	300 mg	2.65	2.52
Clavulanate Potassium	100 mg	12.81	12.17
Clindamycin Phosphate (Cleocin) (Dosage change from 300 mg to 150 mg)	150 mg	1.19	1.13
** Cubicin (See Daptomycin)				A
Dantrolene Sodium	20 mg	73.00	69.35
** Daptomycin (Cubicin) - A lipopeptide antibiotic injection-Covered ICD-9's - 035, 373.13, 376.01, 380.10 - 380.16, 528.5, 608.4, 616.4, 680.0 - 680.9, 681.0 - 681.9, 682.0 - 682.9, 685.0, 686.00 - 686.09, 686.1 - 686.9	500mg	153.32	145.65	A
Denileukin Difitox, Ontak (For 300 mcg, see J9160)	150 mcg	595.43	565.66
Dextrose 2.5%	2.50%	7.68	7.30
Dextrose 5%	5%	7.86	7.47
Dextrose 10%	500 ml	10.00	9.50
Dextrose 50%	50%	10.32	9.80
**Dextrose/Nitroglycerin 5%-20 mg/ 100 ml/250 ml	20 mg/100 ml/250 ml	6.32	6.00
**Dextrose 5%/ Sodium Chloride	1000 ml	11.22	10.66
Diltiazem Hcl. (Cardizem IV)	5 mg	1.73	1.64
** Doxycycline Hyclate	100 mg	13.45	12.78
Edrophonium Chloride (Tensilon) (Allow for ICD9—358.0)	10 mg	0.59	0.56
** Enalaprilat (Vasotec IV)	1.25 mg	3.65	3.47
** Erbitux (see cetuximab)				A
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office	500,000 IU/ 1ml	29.84	28.35
Esmolol Hcl. (Brevibloc) Covered when administered in the doctor office or ambulance. Covered ICD-9 = 427.89 (Dosage change from 10 mg to 100 mg)	100 mg	18.76	17.82
Estradiol	1 gram	13.30	12.64
** Estradiol Pellets	Per Pellet	Invoice	Invoice
** Ethiodized Oil (Ethiodol)	1 ml	8.06	7.66
Ethracrynate Sodium (Edecrin Sodium)	50 mg	20.23	19.22
** Etoposide Phosphate (Etopophus) J9999 covered diagnoses = 151.0-151.9, 155.0, 155.2, 160.0-160.9, 162.0-162.9, 170.0-171.9, 173.0-176.9, 182.0-183.9, 186.0-186.9, 188.0-189.9, 190.5, 191.0-191.9, 194.0-195.8, 200.00 to 207.01, 236.1.	100mg	126.19	119.88
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	1.60	1.52
** Flumazenil (Mazicon, Romazicon)	0.1 mg/ml	9.57	9.09
Flumazenil (Mazicon, Romazicon)	0.5 mg/ml	42.83	40.69
Folic Acid	5 mg	1.02	0.97
Gallium Nitrate (Ganite) ICD'9 275.42 plus secondary DX for malignancy	25mg/ml	7.24	6.88
** Gatifloxacin (Tequin)	200 mg	18.15	17.24
Glycopyrrolate (Robinul)	0.2mg	0.71	0.67
Goserelin Acetate (use code J9202 per 3.6mg)	10.8 mg	1,198.48	1,138.56
Heparin Sodium	100 units	0.47	0.45
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm/500 ml	4.89	4.65
**J3590 Hyaluronan, High Molecular Weight (Orthovisc®) 30 mg/2ml Billed with CPT code 20610 for coverered indications of osteoarthritis of the knee (715.16, 715.26, 715.36, or 715.96). One injection per week per knee.	30mg/2ml	238.36	226.44	A
** Inamrinone Lactate	5 mg	4.05	3.85
** Isopropyl Alchol/Peginterferon Alfa-2A (Pegasys) Covered indication 070.54 when administered in the office	180 mcg/ml	331.74	315.15
Isoproterenol Hydrochloride (Considered Part of Procedure)	0.2 mg	0.65	0.62
** Ketamine Hcl. (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.	50 mg/ml	0.73	0.69
**Labetalol Hcl (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses.	20 mg	1.00	0.95
** Laronidase (Aldurazyme)	0.58mg/ml	128.82	122.38
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable separately when billed with any other procedures	2.5 mg/ml	0.31	0.29
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug.	0.5 mg	62.01	58.91
Lidocaine Hcl. (Xylocaine-MPF) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable when billed with any other procedure.	2% 5 ml	3.57	3.39
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	0.68	0.65
Metronidazole Hcl. (Flagyl IV) IV in the office	500 mg	21.71	20.62
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride	100 mg	39.42	37.45
Morrhuate Sodium	50 mg	1.40	1.33
Nafcillin (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	2.41	2.29
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nitroglycerin IV – Allowed in the Office or Ambulance – In emergency situation. (Dosage Change from 25 mg to 5 mg)	5 mg	0.42	0.40
**Normal Saline (Sterile Water)	50 ml	1.43	1.36
Ofloxacin (Floxin IV), 20 mg		Invoice	Invoice
** Omalizumab (Xolair) J3490 Covered indication Extrinsic Asthma Unspecified (493.00).	150 mg	514.19	488.48	A
**J3590 Orthovisc® (See High Molecular Weight Hyaluronan)				A
**Oxychlorosene Sodium (Clorpactin WCS-90)	1GM	1.85	1.76
** Palonosetron Hcl. (Aloxi)	0.25mg/5ml SDV	307.80	292.41
** Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	22.80	21.66
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys) Covered indication 070.54 when administered in the office	180mcg/ml	331.74	315.15
** Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication 070.54 when administered in the office.	50 mcg	320.61	304.58
** Peginterferon Alfa-2B, 80mcg	80 mcg	336.60	319.77
** Peginterferon Alfa-2B, 120mcg	120 mcg	353.46	335.79
** Peginterferon Alfa-2B, 150mcg	150 mcg	371.12	352.56
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered		0.00	0.00
** Pemetrexed (Alimta) Covered indications = 163.0 through 163.8	500 mg/SDV	2,315.63	2,199.85	A
** Piperacillin Sodium (Pipracil)	1 gm	7.00	6.65
Potassium Acetate	2 meq	0.07	0.07
Procaine Hydrochloride	1%	2.36	2.24
Procaine Hydrochloride	2%	3.40	3.23
Propofol (Diprivan) (Carrier does not pay separately)	10 mg	0.04	0.04
Rifampin	600 mg	76.74	72.90
**Secretin (SecreFlo) Used in secretin stimulation testing		Invoice	Invoice	A
** SMZ-TMP (Sulfamethoxazole/Trimethoprim) Documentation as to why the patient needs to be on IV infusion instead of oral medication, must be in block 19 or as an attachment for paper claims or in the notepad for EMC claims.	5ml	3.05	2.90
Sincalide (Kinevac) (Use A4641/Carrier Pays Radiopharmaceuticals by Invoice)	5 mcg	29.41	27.94
Sodium Acetate	100 meq	3.49	3.32
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	2.73	2.59
Sodium Bicarbonate (NACH03)	8.4%/1ml	0.04	0.04
Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	0.97	0.92
**Somavert (See Pegvisomant for Injection)
** Sufentanil Citrate (Sufenta) Separate payment allowed when billed with 62310, 62311, 62318, 62319, 76005, 95990, or 96530. If billed with any other procedures, it will be considered part of the procedure and separate payment will not be allowed.	50mcg/ml	9.81	9.32
Testosterone	37.5 mg	0.11	0.10
** Testosterone Pellets (Testopel)	Per Pellet	Invoice	Invoice
Tetanus Toxoid (use codes 90702, 90703, and 90718)		12.86	12.22
Valproate Sodium (Depacon) IV, Covered ICD9's = 345.00 - 345.91, Allowed when administered IV, in the physician's office. (Dosage change from 500 mg to 100 mg)	100 mg	2.02	1.92
Vasopressin	20 units/ml	5.91	5.61
Verapamil Hcl. (Isoptin IV) (Dosage Change from 5 mg to 2.5 mg)	2.5 mg	0.98	0.93
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	0.93	0.88
Vitamin C (Ascorbic Acid) (Non-covered by Carrier)	500 mg	0.59	0.56
**Water, Sterile, 1000 ml	1000 ml	5.64	5.36
** Xolair (See Omalizumab)				A

NOTE: Although this file may list a drug and an associated Medicare allowed amount, it does not necessarily follow that the drug is covered by Medicare and, if covered, whether payment may be due in a particular circumstance. Medicare contractors separately determine whether a particular drug meets the program's requirements for coverage and, if covered, whether payment may be made for the drug in the circumstance under which it was furnished.

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")

Part B Not Otherwise Classified Drug Fee Schedule

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