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January 5, 2007

2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

2006 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective April 1, 2006 through June 30, 2006

Revised 01/04/2007

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

NOTE 1: Payment allowance limits subject to the ASP methodology are based on 4Q05 ASP data.

NOTE 2: Providers should contact their local Medicare contractor processing the claim for the most appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.

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.

DRUG NAME	DOSAGE	Current PAR	Current NON-PAR
Abatacept (Orencia) Covered indications 714.0, 714.1, 714.2, or 714.81	250 mg	$477.000	$453.150
**Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	$2.290	$2.176
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	$390.975	$371.426
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.041	$0.039
Apomorphine Hydrochloride (Apokyn)	10 mg	$25.839	$24.547
Arginine Hydrochloride (R-Gene 10)	300 ml	$10.324	$9.808
Ascorbic Acid (see Vitamin C)	250 mg	$0.093	$0.088
**Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg/ml	$0.800	$0.760
Atropine Sulfate / Edrophonium Chloride	10 mg	$5.736	$5.449
Aztreonam (Azactam)	500 mg	$11.092	$10.537
** Bacitracin (Bacim)	50,000 U	$10.170	$9.662
Boniva (see Ibandronate Sodium injection)
Bretylium Tosylate (Bretylol)	5 mg	$0.175	$0.166
Brevibloc (See Esmolol Hydrochloride)
Bumetanide (Bumex)	0.25 mg	$0.256	$0.243
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)	2 ml	$0.140	$0.133
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)	2 ml	$0.260	$0.247
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.	0.25% - 1 ml	$0.043	$0.041
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.	0.50% - 1 ml	$0.043	$0.041
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.	0.75% - 1 ml	$0.043	$0.041
Calcium Chloride	100 mg/ml	$1.456	$1.383
Cardizem IV (see Diltiazem Hydrochloride)
** Cefamanadole Nafate (Mandol)	1 gm	$8.610	$8.180
** Cefoperazone Sodium (Cefobid)	1 gram	$16.380	$15.561
Cefotetan Disodium (Cefotan)	1 gram	$9.490	$9.016
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.02 or 787.03	150 mg	$0.557	$0.529
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$11.056	$10.503
Clindamycin Phosphate (Cleocin)	150 mg	$3.073	$2.919
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate	0.4 mg	$0.070	$0.067
Dantrolene Sodium	20 mg	$78.800	$74.860
Decitabine (Dacogen)- Covered ICD-9's=238.7	50 mg	$1325.000	$1258.750
Depacon (see Valproate Sodium)
Denileukin Difitox (Ontak) (For 300 mcg, use code J9160)	150 mcg	$595.430	$565.659
Dextrose 2.5%	2.50%	$7.680	$7.296
Dextrose 5%	5%	$7.860	$7.467
Dextrose 10%	500 ml	$10.000	$9.500
Dextrose 50%	50 ml	$0.550	$0.523
**Dextrose / Nitroglycerin 5%-20 mg/ 100 ml/250 ml	20 mg/100 ml/250 ml	$6.320	$6.004
**Dextrose 5% / Sodium Chloride	1000 ml	$11.220	$10.659
Diprivan (see Propofol)
Diltiazem Hydrochloride (Cardizem IV)	5 mg	$0.256	$0.243
Doxycycline Hyclate	100 mg	$11.071	$10.517
Edecrin Sodium (See Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	$0.520	$0.494
Enalaprilat (Vasotec IV)	1.25 mg	$1.615	$1.534
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office	500,000 IU/ 1ml	$29.840	$28.348
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 = 427.89 (Dosage change from 100 mg to 10 mg.)	10 mg	$0.978	$0.929
Estradiol	1 gram	$13.300	$12.635
** Estradiol Pellets	Per Pellet	Invoice	Invoice
** Ethiodized Oil (Ethiodol)	1 ml	$8.060	$7.657
Ethacrynate Sodium (Edecrin Sodium)	50 mg	$19.040	$18.088
Etomidate (Amidate)	2 mg	$0.660	$0.627
Euflexxa (see Hyaluronate Sodium)
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	$0.266	$0.253
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)	0.1 mg	$3.599	$3.419
Folic Acid	5 mg	$0.868	$0.825
Glycopyrrolate (Robinul)	0.2mg	$0.305	$0.290
Graftjacket Gel	1 cc	$883.205	$839.045
**Heparin Sodium	100 units	$0.032	$0.030
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm	$23.040	$21.888
Hyaluronate Sodium (Euflexxa)	1 mg	$6.182	$5.873
Ibandronate Sodium injection (Boniva) Covered for postmenopausal osteoporosis (733.01 or 733.09)	3 mg / 3 ml	$427.964	$406.566
** Inamrinone Lactate	5 mg	$4.050	$3.848
Isoproterenol Hydrochloride (Isuprel)	0.2 mg	$0.667	$0.634
Isoptin IV (see Verapamil Hydrochloride)
Isuprel (see Isoproterenol Hydrochloride)
Ketamine Hydrochloride (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.	10 mg	$0.010	$0.010
Labetalol Hydrochloride (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.	5 mg	$0.078	$0.074
** 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	$0.310	$0.295
** Levophed Bitartrate (see Norepinephrine Bitartrate)
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug.	0.5 mg	$62.010	$58.910
Lidocaine - 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.	1 ml	$0.120	$0.114
Mandol (See Cefamanadole Nafate)
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	$0.275	$0.261
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered for ICD-9's= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0-567.9, 599.0-599.9, 615.0-615.9.	500 mg	$1.381	$1.312
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Morrhuate Sodium	50 mg	$1.681	$1.597
Nafcillin Sodium (Nallpen)	1 gm	$0.380	$0.361
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nitroglycerin IV û Allowed in emergency situations.	5 mg	$0.102	$0.097
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow in emergency situations.	1 mg	$2.161	$2.053
Norcuron (see Vecuronium Bromide)
Normal Saline (Sterile Water)	50 ml	$1.430	$1.359
Ofloxacin (Floxin IV), 20 mg		Invoice	Invoice
Ontak (see Denileukin Difitox)
Orencia (see Abatacept)
Orthovisc« (see Sodium Hyaluronate)
**Oxychlorosene Sodium (Clorpactin WCS-90)	1 gm	$1.850	$1.758
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	$3.836	$3.644
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys«) Covered indication 070.54 when administered in the office	180mcg/ml	$322.669	$306.536
** Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication 070.54 when administered in the office.	50 mcg	$320.610	$304.580
** Peginterferon Alfa-2B, 80mcg	80 mcg	$336.600	$319.770
** Peginterferon Alfa-2B, 120mcg	120 mcg	$353.460	$335.787
** Peginterferon Alfa-2B, 150mcg	150 mcg	$371.120	$352.564
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered
Pepcid (See Famotidine)
Potassium Acetate	2 meq	$0.036	$0.034
Potassium Phosphate	3 mmol	$0.076	$0.072
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Propofol (Diprivan)	10 mg	$0.274	$0.260
Protonix IV (see Pantoprazole Sodium)
**R-Gene 10 (See Arginine Hcl.)
Rifampin	600 mg	$52.110	$49.505
Robinul (see Glycopyrrolate)
Sarracenia Purpura	1 ml	$0.504	$0.479
**Secretin (SecreFlo) Used in secretin stimulation testing		Invoice	Invoice
** 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	$3.050	$2.898
Sodium Acetate	2 meq	$0.036	$0.034
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	$0.860	$0.817
Sodium Chloride, Hypertonic	250 cc	$1.199	$1.139
Sodium Hyaluronate (Orthovisc«), For Intra-Articular Injection - Billed with CPT code 20610 for covered indications of osteoarthritis of the knee (715.16, 715.26, or 715.96). One injection per knee per week.	30 mg	$199.503	$189.528
Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.166	$0.158
**Somavert (See Pegvisomant for Injection)
Sterile Saline / Water	5 cc	$0.052	$0.049
**Sterile Saline / Water, 1000 ml	1000 ml	$5.640	$5.358
** 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	$9.810	$9.320
Tagamet (See Cimetidine Hydrochloride)
Tensilon (See Edrophonium Chloride)
Testosterone	37.5 mg	$0.110	$0.105
** Testosterone Pellets (Testopel)	Per Pellet	Invoice	Invoice
Tetanus Toxoid (use codes 90702, 90703, or 90718)
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	$1.037	$0.985
Vasopressin	20 units	$0.900	$0.855
Vasotec (see Enalaprilat)
Vecuronium Bromide (Norcuron)	1 mg	$0.257	$0.244
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	$0.414	$0.393
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	$0.930	$0.884
Vitamin C (Ascorbic Acid)
HOCM <= 149 MG/ML	1 ml	$0.041	$0.039
HOCM 200 - 249 MG/ML	1 ml	$0.093	$0.088
HOCM 250 - 299 MG/ML	1 ml	$0.100	$0.095
HOCM 300 - 349 MG/ML	1 ml	$0.104	$0.099
HOCM 350 - 399 MG/ML	1 ml	$0.107	$0.102
HOCM >= 400 MG/ML	1 ml	$0.191	$0.181

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")

2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

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