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October 6, 2008

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

2008 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective July 1, 2008 through September 30, 2008

Revised 09.30.2008

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 1Q08 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
** Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	$2.290	$2.176
Alglucoside Alfa (Myozyme)	10 mg			Code for 2008: J0220
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	$397.481	$377.607
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.045	$0.043
Arformoterol Tartrate	15 mcg			Code for 2008: J7605
Arginine Hydrochloride (R-Gene 10)	300 ml	$10.992	$10.442
Ascorbic Acid (Vitamin C) Non-covered by Carrier**
** Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg / ml	$0.800	$0.760
Atropine Sulfate / Edrophonium Chloride	10 mg	$1.146	$1.089
Avastin (See Bevacizumab)
Aztreonam (Azactam)	500 mg	$14.714	$13.978
** Bacitracin (Bacim)	50,000 U	$10.170	$9.662
Bendamustine Hydrochloride (Treanda) Covered indications: 204.10 - lymphoid leukemia, chronic, without mention of remission or 204.11 - lymphoid leukemia, chronic, in remission	1 mg	$19.080	$18.126	Added 07/01/2008
Bevacizumab (Avastin) If billed under J3490 or J3590, the ICD-9 code equals 362.52 and billed with procedure code 67028.		Invoice	Invoice
Bretylium Tosylate (Bretylol)	5 mg	$0.175	$0.166
Brevibloc (see Esmolol Hydrochloride)
Bumetanide (Bumex)	0.25 mg	$0.161	$0.153	(decreased) Revised 10/01/2008
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.25% - 1 ml	$0.060	$0.057
Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.50% - 1 ml	$0.060	$0.057
Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.75% - 1 ml	$0.060	$0.057
Calciferol (see Ergocalciferol D2)
Calcium Chloride	100 mg / ml	$0.074	$0.070
Cardizem IV (see Diltiazem Hydrochloride)
** Cefamanadole Nafate (Mandol)	1 gm	$8.610	$8.180
** Cefoperazone Sodium (Cefobid)	1 gm	$16.380	$15.561
Cefotetan Disodium (Cefotan)	1 gm	$11.376	$10.807
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet) Covered ICD-9's = 787.01, 787.02 or 787.03	150 mg	$0.699	$0.664
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$12.386	$11.767
Clindamycin Phosphate (Cleocin)	150 mg	$1.532	$1.455
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate	0.4 mg	$0.058	$0.055
Dantrolene Sodium	20 mg	$78.800	$74.860
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	$0.101	$0.096
** 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
Diltiazem Hydrochloride (Cardizem IV)	5 mg	$0.157	$0.149	(decreased) Revised 10/01/2008
Diprivan (see Propofol)
Doripenem (Doribax)	10 mg	$0.709	$0.674	Added 07/01/2008
Doxapram Hydrochloride (Dopram)	20 mg	$1.522	$1.446	(decreased) Revised 10/01/2008; Added 07/01/2008
Doxycycline Hyclate	100 mg	$4.673	$4.439
Eculizumab (Soliris)	10 mg			Code for 2008: J1300
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	$0.608	$0.578	(increased)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)	1.25 mg	$1.388	$1.319
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	$0.584	$0.555	(decreased) Revised 10/01/2008
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.	20 MG	$1.826	$1.735
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	$0.526	$0.500
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	$0.371	$0.352	(decreased) Revised 10/01/2008
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)	0.1 mg	$2.022	$1.921	(decreased) Revised 10/01/2008
Flumazenil (Mazicon, Romazicon)	0.5 mg	$42.830	$40.689
Folic Acid	5 mg	$1.343	$1.276
Fosaprepitant Dimeglumine (Emend) Allowed when billed on the same day as chemotherapy.	1 mg	$1.613	$1.532	Added 07/01/2008
Glycopyrrolate (Robinul)	0.2mg	$0.251	$0.238
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
Idursulfase	1 mg			Code for 2008: J1743
** 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)
Ixabepilone (Ixempra) Covered for metastatic or locally advanced breast cancer (ICD-9 codes 174.0 - 175.9)	1 mg	$63.743	$60.556
Kenalog (see Triamcinolone Acetonide, Preserative Free)
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	$0.082	$0.078
Lanreotide (Somatuline Depot)	1 mg	$25.955	$24.657
Levetiracetam (Keppra intraveneous)	10 mg	$0.391	$0.371
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76003, 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
Lexiscan (see Regadenoson)
Lidocaine - Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. Not payable when billed with any other procedure.	1 ml	$0.129	$0.123
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Mandol (see Cefamanadole Nafate)
Mazicon (see Flumazenil)
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	$0.243	$0.231
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	$1.485	$1.411	(decreased) Revised 10/01/2008
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium	50 mg	$2.047	$1.945
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	$6.280	$5.966	(increased) Revised 10/01/2008
Nalmefene Hydrochloride (Revex)	10 mcg	$0.267	$0.254	(decreased) Revised 10/01/2008; Added 07/01/2008
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV - Allowed in emergency situations.	5 mg	$0.323	$0.307	(decreased) Revised 10/01/2008
Nodolo & Tusal (see Sodium Thiosalicylate)
** 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
Normodyne (see Labetalol Hydrochloride)
NplateT (see Romiplostim)
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	$1.130	$1.074
Ontak (see Denileukin Difitox)
Optison		Invoice	Invoice
** Oxychlorosene Sodium (Clorpactin WCS-90)	1 gm	$1.850	$1.758
Panitumumab (Vectibix) Covered indications-153.0-154.8	10 mg			Code for 2008: J9303
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	$4.097	$3.892
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) Covered indication 070.54 when administered in the office.	180mcg/ml	$480.273	$456.259
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	$0.020	$0.019
Potassium Phosphate	3 mmol	$0.026	$0.025
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Propofol (Diprivan)	10 mg	$0.177	$0.168
Protonix IV (see Pantoprazole Sodium)
** R-Gene 10 (see Arginine Hcl.)
Ranibizumab Injection (Lucentis)	1 mcg			Code for 2008: J2778
Regadenoson (Lexiscan)	Invoice	Invoice	Invoice
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
Rifampin	600 mg	$122.960	$116.812
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Romiplostim (NplateT) Covered for Immune Thrombocytopenic Purpura (idiopathic thrombocytopenic purpura / tidal platelet dysgenesis) - 287.31	10 mcg	$45.050	$42.798	Effective 08/25/2008
Sarracenia Purpura Non-covered by Carrier
** Secretin (SecreFlo) Used in secretin stimulation testing		Invoice	Invoice
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sodium Acetate	2 meq	$0.020	$0.019
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	$0.103	$0.098
Sodium Chloride, Hypertonic	250 cc	$0.643	$0.611	(decreased) Revised 10/01/2008
** Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.123	$0.117
Soliris (see Eculizumab)				Code for 2008: J1300
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)	5 cc	$0.052	$0.049
Sterile Saline / Water	1000 ml	$5.640	$5.358
** Sterile Saline / Water, 1000 ml	50mcg/ml	$9.810	$9.320
** 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.
Sulfamethoxazole/Trimethoprim (SMZ-TMP) 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.	400 - 80 mg	$0.216	$0.205
Synthroid (see Levothyroxine Sodium)
Tagamet (see Cimetidine Hydrochloride)
Temsirolimus (Torisel) Covered indication is for the treatment of advanced renal cell carcinoma (189.0 Malignant neoplasm of kidney, except pelvis). Supplied as a kit containing 25 mg vial of temsirolimus and vial of diluent.	Per 25 mg Kit	$1,194.037	$1,134.335
Tenormin (see Atenolol)
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
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Triamcinolone Acetonide, Preservative Free (Kenalog)	1 mg	$3.286	$3.122	Added 07/01/2008
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	$0.682	$0.648
Vasopressin	20 units	$1.731	$1.644
Vasotec (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)	1 mg	$0.222	$0.211
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	$1.508	$1.433
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	$0.930	$0.884
Vitamin C (see Ascorbic Acid) Non-covered by Carrier**
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

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")

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

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