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January 31, 2007

1st Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

2007 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective January 1, 2007 through March 31, 2007

Revised 01/31/2007

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	Notes
Abatacept (Orencia) Covered indications 714.0, 714.1, 714.2, or 714.81 Effective 01/01/2007 use code J0129	250 mg	$467.460	$444.087	New code for 2007 J0129
**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	$425.815	$404.524
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.500	$0.475
Apomorphine Hydrochloride (Apokyn) Considered usually self-administered by this carrier. Effective 01/01/2007 use code J0364	10 mg	$25.863	$24.570	New code for 2007 J0364
Arginine Hydrochloride (R-Gene 10)	300 ml	$11.003	$10.453
Arranon (See Nelarabine Injection)
** Ascorbic Acid (see Vitamin C)	250 MG	$0.096	$0.091
** Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg/ml	$0.800	$0.760
Atropine Sulfate / Edrophonium Chloride	10 mg	$5.664	$5.381
Aztreonam (Azactam)	500 mg	$11.963	$11.365
** 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	$0.223	$0.212
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	$0.056	$0.053
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	$0.056	$0.053
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	$0.053	$0.050
Calcium Chloride	100 mg/ml	$0.049	$0.047
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	$0.624	$0.593
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$11.209	$10.649
Clindamycin Phosphate (Cleocin)	150 mg	$1.648	$1.566
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate	0.4 mg	$0.041	$0.039
Dantrolene Sodium	20 mg	$78.800	$74.860
Decitabine (Dacogen) Covered indications: 238.7 through 238.79 Effective 01/01/2007 use code J0894 per 1 mg	50mg / SDV	$1325.000	$1258.750	New Code for 2007 J0894
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	$0.130	$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	$0.195	$0.185
Doxycycline Hyclate	100 mg	$4.839	$4.597
Edecrin Sodium (See Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	$0.560	$0.532
Enalaprilat (Vasotec IV)	1.25 mg	$2.052	$1.949
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	$1.572	$1.493
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	$0.591	$0.561
Euflexxa (see Hyaluronate Sodium)
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	$0.267	$0.254
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)	0.1 mg	$4.256	$4.043
Flumazenil (Mazicon, Romazicon)	0.5 mg	$42.830	$40.689
Folic Acid	5 mg	$1.024	$0.973
Galsulfase (Naglazyme) Effective 01/01/2007, use code J1458	1 mg	$303.224	$288.063	New Code for 2007 J1458
Glycopyrrolate (Robinul)	0.2mg	$0.301	$0.286
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) Effective 01/01/2007, use code Q4085 per dose	1 mg	$6.182	$5.873	New Code for 2007 Q4085
Ibandronate Sodium injection (Boniva) Covered for postmenopausal osteoporosis (733.01 or 733.09) Effective 01/01/2007, use code J1740 per 1 mg	3 mg / 3 ml	$427.964	$406.566	New Code for 2007 J1740
Idursulfate	1 mg	$464.315	$441.099
Immune Globulin Subcutaneous (Vivaglobin) Covered for the following indications when administered in POS 11: ICD-9 codes 279.04, 279.05, 270.06, 279.12, 279.2. Effective 01/01/2007, use code J1562	100 mg/ ml	$12.720	$12.084	New Code for 2007 J1562
** 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	$0.081	$0.077
Lucentis (See Ranibizumab)
Mandol (See Cefamanadole Nafate)
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	$0.252	$0.239
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	$1.520	$1.444
Micafungin Sodium (Mycamine) Covered indications ICD-9's 112.84 or V42.81 Effective 01/01/2007, use code J2248	1 mg	$1.866	$1.773	New Code for 2007 J2248
Micafungin Sodium (Mycamine) Covered indications ICD-9's 112.84 or V42.81 Effective 01/01/2007, use code J2248 per 1 mg	50 mg	$99.110	$94.155	New Code for 2007 J2248
Miconazole (Monistat IV) 10 mg		$Invoice	$Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Morrhuate Sodium	50 mg	$1.681	$1.597
Mycamine (see Micafungin Sodium)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	$4.660	$4.427
Naltrexone Effective 01/01/2007, use code J2315	1 mg	$1.939	$1.842	New Code for 2007 J2315
Nelarabine Injection (Arranon) Effective 01/01/2007, use code J9261 per 50 mg	5MG/ML	$8.480	$8.056	New Code for 2007 J9261
Netilmicin Sulfate (Netromycin), 150 mg		$Invoice	$Invoice
Nitroglycerin IV û Allowed in emergency situations.	5 mg	$0.206	$0.196
** 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	1 mg	$8.480	$8.056
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	$3.995	$3.795
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys«) Covered indication 070.54 when administered in the office	180mcg/ml	$337.572	$320.693
** 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	$0.027	$0.026
Potassium Phosphate	3 mmol	$0.042	$0.040
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Propofol (Diprivan)	10 mg	$0.171	$0.162
Protonix IV (see Pantoprazole Sodium)
**R-Gene 10 (See Arginine Hcl.)
Ranibizumab Injection (Lucentis)	50 mg	$2036.175	$1934.366
Rifampin	600 mg	$52.618	$49.987
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	$0.021	$0.020
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	$0.177	$0.168
Sodium Chloride, Hypertonic	250 cc	$1.138	$1.081
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. Effective 01/01/2007, use code Q4086 per dose	30 mg	$201.082	$191.028	New Code for 2007 Q4086
Sodium Tetradecyl Sulfate (Sotradecol)		$Invoice	$Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.132	$0.125
**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
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)
** 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
Tetracycline		$Invoice	$Invoice
Tigecycline Effective 01/01/2007, use code J3243 per 1 mg	1 mg	$0.909	$0.864	New Code for 2007 J3243
Tigecycline (Tygacil) Effective 01/01/2007, use code J3243 Per 1 mg	50 mg/SDV	$51.562	$48.984	New Code for 2007 J3243
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	$1.169	$1.111
Vasopressin	20 units	$2.027	$1.926
Vasotec (see Enalaprilat)
Vecuronium Bromide (Norcuron)	1 mg	$0.239	$0.227
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	$0.374	$0.355
** 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