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April 3, 2009 - Updated 10.26.09

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

2009 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective April 1, 2009 through June 30, 2009

Revised: 09/24/2009

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 4Q08 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
DRUG NAME	DOSAGE	Current PAR	Current NON-PAR	Notes
Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	$1.425	$1.354
Alglucoside Alfa (Myozyme)	10 mg			Code for 2009: 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	$383.647	$364.465
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.036	$0.034
Antihemophilic Factor (Recomb) Plasma/Albumin-Free (Xyntha)	1 IU	$1.047	$0.995
Arformoterol Tartrate (Brovana)	15 mcg			Code for 2009: J7605
Arginine Hydrochloride (R-Gene 10)	300 ml	$11.003	$10.453
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	$16.970	$16.122
** 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			Code for 2009: J9033
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)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)	0.25 mg	$0.175	$0.166
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	$0.058	$0.055
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	$0.058	$0.055
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	$0.058	$0.055
Calciferol (see Ergocalciferol D2)
Calcium Chloride	100 mg / ml	$0.093	$0.088
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
Certolizumab Pegol (Cimzia)	1 mg	$3.515	$3.339
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet)	150 mg	$0.755	$0.717
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$12.129	$11.523
Clevidipine Butyrate	1 mg	$4.578	$4.349
Clindamycin Phosphate (Cleocin)	150 mg	$1.532	$1.455
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate	0.4 mg	$0.064	$0.061
Cosyntropin IV	0.25 mg	$75.582	$71.803
Dantrolene Sodium	20 mg	$78.800	$74.860
Degarelix (a gonadotropin-releasing hormone (GnRH) receptor antagonist) Covered ICD-9 = 185	20 mg	$82.415	$78.294	Effective 03/01/2009
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	$0.161	$0.153
Diprivan (see Propofol)
Doripenem (Doribax)	10 mg			Code for 2009: J1267
Doxapram Hydrochloride (Dopram)	20 mg	$1.903	$1.808
Doxycycline Hyclate	100 mg	$9.421	$8.950
Eculizumab (Soliris)	10 mg			Code for 2009: J1300
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	$0.608	$0.578
Elaprase (see Idursulfase)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)	1.25 mg	$1.294	$1.229
Eovist (see Gadoxetate Disodium)
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	$0.594	$0.564
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.	20 MG	$2.022	$1.921
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	$0.538	$0.511
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	$0.420	$0.399
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)	0.1 mg	$1.553	$1.475
Flumazenil (Mazicon, Romazicon)	0.5 mg	$42.830	$40.689
Folic Acid	5 mg	$1.356	$1.288
Fosaprepitant Dimeglumine (Emend) Allowed when billed on the same day as chemotherapy.	1 mg			Code for 2009: J1453
Gadoxetate Disodium (Eovist)	1 ml	$13.780	$13.091
Glycopyrrolate (Robinul)	0.2mg	$0.218	$0.207
Graftjacket Gel	1 cc			Code for 2009: Q4113
** Heparin Sodium	100 units	$0.032	$0.030
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm	$23.040	$21.888
Hylan G-F 20 (Synvisc-One) Covered indications: 715.16, 715.26, 715.36 or 715.96 when billed with 20610.	48 mg	$559.023	$531.072
Idursulfase (Elaprase)	1 mg			Code for 2009: 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			Code for 2009: J9207
Kenalog (see Triamcinolone Acetonide)
Keppra intraveneous (see Levetiracetam)
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	$0.081	$0.077
Lanreotide (Somatuline Depot)	1 mg			Code for 2009: J1930
Levetiracetam (Keppra intraveneous)	10 mg			Code for 2009: J1953
** 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, 77033, 95990, or 96530. Not payable when billed with any other procedure.	1 ml	$0.144	$0.137
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Mandol (see Cefamanadole Nafate)
Mazicon (see Flumazenil)
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	$0.198	$0.188
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	$1.442	$1.370
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium	50 mg	$2.004	$1.904
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	$7.090	$6.736
Nalmefene Hydrochloride (Revex)	10 mcg	$0.276	$0.262
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency situations.	5 mg	$0.345	$0.328
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)
Nplate™ (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	$1.210	$1.150
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 2009: J9303
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	$4.604	$4.374
** 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	$0.021	$0.020
Potassium Phosphate	3 mmol	$0.030	$0.029
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Propofol (Diprivan)	10 mg	$0.088	$0.084
Protonix IV (see Pantoprazole Sodium)
** R-Gene 10 (see Arginine Hcl.)
Ranibizumab Injection (Lucentis)	1 mcg			Code for 2009: J2778
Regadenoson (Lexiscan)	0.1 mg			Code for 2009: J2785
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
Rifampin	600 mg	$41.531	$39.454
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Romiplostim (Nplate™) Covered for Immune Thrombocytopenic Purpura (idiopathic thrombocytopenic purpura / tidal platelet dysgenesis) - 287.31	10 mcg	$44.809	$42.569	(decreased); Updated October 2009
Sarracenia Purpura Non-covered by Carrier
Secretin (SecreFlo) Used in secretin stimulation testing	1 mcg			Code for 2009: J2850
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	$0.104	$0.099
Sodium Chloride, Hypertonic	250 cc	$0.603	$0.573
** Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.141	$0.134
Soliris (see Eculizumab)
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	$0.237	$0.225
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
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).	1 mg			Code for 2009: J9330
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	1 mg			Code for 2009: J3300
Triamcinolone Acetonide (Kenalog)	10 mg			Code for 2009: J3301
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	$0.641	$0.609
Vasopressin	20 units	$1.610	$1.530
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)	1 mg	$0.179	$0.170
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**
Xyntha (see Antihemophilic Factor (Recomb) Plasma/Albumin-Free
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