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July 3, 2007

3rd Quarter Update -- Part B Not Otherwise Classified Drug Fee Schedule

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

Effective June 1, 2007 through September 30, 2007

Revised: 07/02/2007

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

NOTE 1: Payment allowance limits subject to the ASP methodology are based on 4Q06 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
**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	410.451	389.928	(decreased)
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	(decreased)
Apomorphine Hydrochloride (Apokyn) Considered usually self-administered by this carrier. Effective 01/01/2007 use code J0364
Arformoterol Tartrate	15 MCG	$4.887	4.643	added 07/01/2007
Arginine Hydrochloride (R-Gene 10)	300 ml	11.003	10.453
Arranon (see Nelarabine Injection)
Ascorbic Acid (Vitamin C)	250 MG	0.091	0.086	(decreased)
** Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg/ml	0.800	0.760
Atropine Sulfate / Edrophonium Chloride	10 mg	5.712	5.426	(decreased)
Avastin (See Bevacizumab)
Aztreonam (Azactam)	500 mg	12.511	11.885	(increased)
** Bacitracin (Bacim)	50,000 U	10.170	9.662
Bevacizumab (Avastin)	25 MG/ML	182.188	173.079
Boniva (see Ibandronate Sodium injection)
Bretylium Tosylate (Bretylol)	5 mg	0.175	0.166
Brevibloc (see Esmolol Hydrochloride)
Bumetanide (Bumex)	0.25 mg	0.222	0.211	(increased)
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	(decreased)
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	(decreased)
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	0.056	0.053	(decreased)
Calcium Chloride	100 mg/ml	0.040	0.038	(decreased)
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	0.642	0.610	(increased)
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	10.958	10.410	(decreased)
Clindamycin Phosphate (Cleocin)	150 mg	1.609	1.529	(increased)
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate	0.4 mg	0.044	0.042	(increased)
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
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	0.134	0.127	(decreased)
**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	0.186	0.177	(increased)
Doxycycline Hyclate	100 mg	4.042	3.840	(decreased)
Eculizumab	1 MG	$17.638	16.756	added 07/01/2007
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	0.511	0.485	(decreased)
Enalaprilat (Vasotec IV)	1.25 mg	2.046	1.944	(decreased)
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	1.176	1.117	(decreased)
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.	20 MG	$0.939	0.892	(decreased)
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	(increased)
Euflexxa (see Hyaluronate Sodium)
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	0.244	0.232	(decreased)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)	0.1 mg	3.412	3.241	(decreased)
Flumazenil (Mazicon, Romazicon)	0.5 mg	42.830	40.689
Folic Acid	5 mg	1.887	1.793	(increased)
Galsulfase (Naglazyme) Effective 01/01/2007, use code J1458
Glycopyrrolate (Robinul)	0.2mg	0.279	0.265	(decreased)
Graftjacket Gel	1 cc	883.205	839.045
HepaGamB Intravenous	0.5 ML	$64.736	61.499	added 07/01/2007
**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
Ibandronate Sodium injection (Boniva) Covered for postmenopausal osteoporosis (733.01 or 733.09) Effective 01/01/2007, use code J1740 per 1 mg
Idursulfate	1 mg	455.030	432.279
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
** 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	0.080	0.076	(decreased)
** 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	0.226	0.215	(increased)
Lucentis (see Ranibizumab)
Mandol (see Cefamanadole Nafate)
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	0.214	0.203	(decreased)
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	1.569	1.491	(decreased)
Micafungin Sodium (Mycamine) Covered indications ICD-9's 112.84 or V42.81 Effective 01/01/2007, use code J2248 per 1 mg
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Morrhuate Sodium	50 mg	1.682	1.598	(decreased)
Mycamine (see Micafungin Sodium)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	4.761	4.523	(increased)
Naltrexone Effective 01/01/2007, use code J2315
Nelarabine Injection (Arranon) Effective 01/01/2007, use code J9261 per 50 mg
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency situations.	5 mg	0.245	0.233	(increased)
** 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
Olanzapine (Zyprexa IM) Covered indications = 295.01 - 295.84 when administered in the physicians office.	0.5 MG	$1.069	1.016	(increased)
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	8.395	7.975	(decreased)
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	2.533	2.406	(decreased)
Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) Covered indication 070.54 when administered in the office	180mcg/ml	356.640	338.808	(increased)
** 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	0.019	0.018	(decreased)
Potassium Phosphate	3 mmol	0.038	0.036	(increased)
Procaine Hydrochloride	1%	2.360	2.242
Procaine Hydrochloride	2%	3.400	3.230
Propofol (Diprivan)	10 mg	0.150	0.143
Protonix IV (see Pantoprazole Sodium)
**R-Gene 10 (see Arginine Hcl.)
Ranibizumab Injection (Lucentis)	0.5 mg	2030.112	1928.606	(decreased)
Rifampin	600 mg	53.615	50.934	(decreased)
Robinul (see Glycopyrrolate)
Sarracenia Purpura	1 ml	0.000	0.000	(decreased)
**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	0.016	0.015	(decreased)
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	2.730	2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	0.060	0.057	(decreased)
Sodium Chloride, Hypertonic	250 cc	1.412	1.341	(increased)
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
Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	0.970	0.922
Sodium Thiosulfate	100 mg	0.128	0.122	(decreased)
**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) Effective 01/01/2007, use code J3243 Per 1 mg
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	1.931	1.834	(increased)
Vasopressin	20 units	2.130	2.024	(decreased)
Vasotec (see Enalaprilat)
Vecuronium Bromide (Norcuron)	1 mg	0.227	0.216	(decreased)
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	0.331	0.314	(decreased)
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	0.930	0.884
Vitamin C (see Ascorbic Acid)
Zyprexa IM (see Olanzapine)
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