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December 3, 2007

4th Quarter 2006 Update Part B Not Otherwise Classified Drug Fee Schedule

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

Effective October 1, 2006 through December 31, 2006

Revised 11/27/2007

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 1Q06 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.

** - Carrier Priced

Changes in Bold

DRUG NAME	DOSAGE	Current PAR	Current NON-PAR
Abatacept (Orencia) Covered indications 714.0, 714.1, 714.2, or 714.81	250 mg	467.460	444.087
** Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	2.290	2.176
Alglucoside Alfa (Myozyme)	1 mg	12.720	12.084
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	367.023	348.672
Amidate (see Etomidate)
Amino Acid	500 ml	21.110	20.055
Amino Acid	1000 ml	35.190	33.431
Aminocaproic Acid	250 mg	0.048	0.046
Apomorphine Hydrochloride (Apokyn)	10 mg	25.863	24.570
Arginine Hydrochloride (R-Gene 10)	300 ml	10.876	10.332
Arranon (See Nelarabine Injection)
** 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	6.319	6.003
Aztreonam (Azactam)	500 mg	11.525	10.949
** 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	0.232	0.220
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	0.050	0.048
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	0.050	0.048
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	0.050	0.048
Calcium Chloride	100 mg/ml	0.044	0.042
Cardizem IV (see Diltiazem Hydrochloride)
** Cefamanadole Nafate (Mandol)	1 gm	8.610	8.180
** Cefoperazone Sodium (Cefobid)	1 gm	16.380	15.561
Cefotetan	l gm	327.231	310.869
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	0.549	0.522
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	11.219	10.658
Clindamycin Phosphate (Cleocin)	150 mg	1.331	1.264
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate	0.4 mg	0.048	0.046
Dantrolene Sodium	20 mg	78.800	74.860
Decitabine (Dacogen) Covered indications: 238.7 - 238.79	1 mg	26.500	25.175
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	0.131	0.124
**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	0.229	0.218
Doxycycline Hyclate	100 mg	4.159	3.951
Edecrin Sodium (See Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	0.524	0.498
Enalaprilat (Vasotec IV)	1.25 mg	2.308	2.193
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	1.585	1.506
Estradiol	1 gram	13.300	12.635
** Estradiol Pellets	Per Pellet	Invoice	Invoice
Ethacrynate Sodium (Edecrin Sodium)	50 mg	19.040	18.088
** Ethiodized Oil (Ethiodol)	1 ml	8.060	7.657
Etomidate (Amidate)	2 mg	0.586	0.557
Euflexxa (see Hyaluronate Sodium)
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	0.242	0.230
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)	0.1 mg	4.543	4.316
Flumazenil (Mazicon, Romazicon)	0.5 mg	42.830	40.689
Folic Acid	5 mg	0.961	0.913
Galsulfase (Naglazyme	1 mg	303.224	288.063
Glycopyrrolate (Robinul)	0.2mg	0.303	0.288
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
Immune Globulin Subcutaneous (Vivaglobin) Covered for the following indications when administered in POS 11: ICDp codes 279.04, 279.05, 270.06, 279.12, 279.2.	100 mg/ ml	12.720	12.084
** Inamrinone Lactate	5 mg	4.050	3.848
Isoproterenol Hydrochloride (Isuprel)	0.2 mg	2.250	2.138
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	0.009	0.009
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	0.077	0.073
Lucentis (See Ranibizumab)
Mandol (See Cefamanadole Nafate)
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	0.266	0.253
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	1.406	1.336
Micafungin Sodium (Mycamine) Covered indications ICD-9's 112.84 or V42.81	50 mg	99.110	94.155
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Morrhuate Sodium	50 mg	1.683	1.599
Mycamine (see Micafungin Sodium)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	5.258	4.995
Naltrexone (Vivitrol)	1 gm	1.939	1.842
Nelarabine Injection (Arranon)	5MG/ML	8.480	8.056
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nitroglycerin IV û Allowed in emergency situations.	5 mg	0.175	0.166
** 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)
Optison		Invoice	Invoice
Orencia (see Abatacept)
Orthovisc« (see Sodium Hyaluronate)
**Oxychlorosene Sodium (Clorpactin WCS-90)	1 gm	1.850	1.758
Panitumumab (Vectibix) Covered indications-153.0-154.8	20 mg	169.600	161.120
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	3.820	3.629
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys«) Covered indication 070.54 when administered in the office	180mcg/ml	344.069	326.866
** 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	0.024	0.023
Potassium Phosphate	3 mmol	0.035	0.033
Procaine Hydrochloride	1%	2.360	2.242
Procaine Hydrochloride	2%	3.400	3.230
Propofol (Diprivan)	10 mg	0.198	0.188
Protonix IV (see Pantoprazole Sodium)
** R-Gene 10 (See Arginine Hcl.)
Ranibizumab Injection (Lucentis)	50 mg	2067.000	1963.650
Rifampin	600 mg	52.661	50.028
Robinul (see Glycopyrrolate)
** 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	0.022	0.021
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	2.730	2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	0.091	0.086
Sodium Chloride, Hypertonic	250 cc	1.001	0.951
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	201.082	191.028
Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	0.970	0.922
Sodium Thiosulfate	100 mg	0.192	0.182
** 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)
Tetracycline		Invoice	Invoice
Tigecycline (Tygacil)	1 mg	0.909	0.864
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	1.273	1.209
Vasopressin	20 units	2.481	2.357
Vasotec (see Enalaprilat)
Vecuronium Bromide (Norcuron)	1 mg	0.255	0.242
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	0.373	0.354
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	0.930	0.884
** Vitamin C (See 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")

4th Quarter 2006 Update Part B Not Otherwise Classified Drug Fee Schedule

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