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July 1, 2010 - Updated 03.28.11

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

2010 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective July 1, 2010 through September 30, 2010

Revised: 03/28/2011

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 1Q10 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
Actemra (see Tocilizumab)
Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	$1.503	$1.428
Alglucosidase Alfa (Myozyme)	10 mg			Code for 2010: 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	$374.559	$355.831
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.040	$0.038
Antihemophilic Factor (Recomb) Plasma/Albumin-Free (Xyntha)	1 IU			Code for 2010: J7185
Arformoterol Tartrate (Brovana)	15 mcg			Code for 2010: J7605
Arginine Hydrochloride (R-Gene 10)	300 ml	$11.003	$10.453
Arzerra (see Ofatumumab)
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	$1.651	$1.568
Avastin (See Bevacizumab)
Aztreonam (Azactam)	500 mg	$17.131	$16.274
** 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 2010: J9033
Berinert (see C1 Esterase Inhibitor)
Bevacizumab (Avastin) If billed under J3490 or J3590, with CPT code 67028 & 1 of the following ICD-9 combinations = 1) 362.01-362.06 (any) with 362.07; 2) 362.35-362.37 (any); 3) 362.02 with 379.23; or 4) 362.52		Invoice	Invoice
Bretylium Tosylate (Bretylol)	5 mg	$0.175	$0.166
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)	0.25 mg	$0.170	$0.162
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	$0.070	$0.067	(increased) Updated April 2011
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	$0.070	$0.067	(increased) Updated April 2012
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	$0.070	$0.067	(increased) Updated April 2013
C1 Esterase Inhibitor (Berinert) - For the treatment of acute abdominal or facial attacks of hereditary angioedema in adult and adolescent patients (277.6)	10 units	$27.528	$26.152
Cabazitaxel (Jevtana®)	60mg / 1.5ml	$8,480.000	$8,056.000	Effective 07/19/2010
Calciferol (see Ergocalciferol D2)
Calcium Chloride	100 mg / ml	$0.129	$0.123
Canakinumab (Ilaris) - For Cryopyrin-associated periodic syndromes	1 mg	$89.847	$85.355
Capsaicin 8% Patch (Qutenza) - Must be administered under provider supervision.	8% Patch, Single Use	$715.500	$679.725	Effective: 04/09/2010
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			Code for 2010: J0718
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet)	150 mg	$0.069	$0.066
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$10.409	$9.889
Cleocin (see Clindamycin Phosphate)
Clevidipine Butyrate	1 mg	$3.070	$2.917
Clindamycin Phosphate (Cleocin)	150 mg	$1.616	$1.535	(decreased) Updated April 2011
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Collagenase Clostridium Histolyticum (Xiaflex) Covered for Contracture of palmar fascia (Dupuytren’s concracture) ICD-9 728.6.	0.1 mg	$382.778	$363.639	Added July 2010
Copper Sulfate	0.4 mg	$0.086	$0.082
Cosyntropin IV	0.25 mg			Code for 2010: J0833
Dantrolene Sodium	20 mg	$78.800	$74.860
Degarelix (Firmagon)	1 mg			Code for 2010: J9155
Depacon (see Valproate Sodium)
Denileukin Difitox (Ontak) (For 300 mcg, use code J9160)	150 mcg	$595.430	$565.659
Denosumab (Prolia ™) ICD-9 = 733.01	60 mg/ml	$874.500	$830.775	Effective 06/01/2010
Dexamethasone Intravitreal Implant (Ozurdex) - For the treatment of macular edema following branch retinal vein occlusion or central retinal vein occlusion. (362.83 PLUS either 362.35 or 362.36)	0.1 mg	$196.100	$186.295
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	$0.149	$0.142
Diprivan (see Propofol)
Dopram (see Doxapram Hydrochloride)
Doripenem (Doribax)	10 mg			Code for 2010: J1267
Doxapram Hydrochloride (Dopram)	20 mg	$1.621	$1.540
Doxycycline Hyclate	100 mg	$13.899	$13.204	(increased) Updated April 2011
Ecallantide (Kalbitor) Covered Indications - 277.6 (accute attack of hereditary angioedema)	1 mg	$280.900	$266.855	Added July 2010
Eculizumab (Soliris)	10 mg			Code for 2010: 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	$1.965	$1.867
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	$0.700	$0.665	(decreased) Updated April 2011
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.	20 MG	$2.285	$2.171
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)	10 mg	$0.367	$0.349	(decreased) Updated April 2011
Ferumoxytol (Feraheme)	1 mg			Codes for 2010: Q0138 (non-esrd) & Q0139 (esrd)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Fludarabine phosphate, oral - Not Covered by Part B	10 mg
Flumazenil (Mazicon, Romazicon)	0.1 mg	$0.843	$0.801	(decreased) Updated April 2011
Flumazenil (Mazicon, Romazicon)	0.5 mg	$42.830	$40.689
Folic Acid	5 mg	$1.395	$1.325	(increased) Updated April 2011
Folotyn (see Pralatrexate)
Fosaprepitant Dimeglumine (Emend) Allowed when billed on the same day as chemotherapy.	1 mg			Code for 2010: J1453
Fospropofol Disodium injection (Lusedra)	35 mg	$1.132	$1.075	Added July 2010
Gadoxetate Disodium (Eovist)	1 ml			Code for 2010: A9581
Glycopyrrolate (Robinul)	0.2 mg	$0.204	$0.194
Graftjacket Gel	1 cc			Code for 2010: 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)	48 mg			Code for 2010: J7325
Idursulfase (Elaprase)	1 mg			Code for 2010: J1743
Ilaris (see Canakinumab)
** Inamrinone Lactate	5 mg	$4.050	$3.848
INTEGRA™ Bilayer Matrix Wound Dressing - Covered Indications = 757.39, 941.20-941.21, 941.24-941.31, 941.34-941.41, 941.44-941.51, 941.54-941.59, 942.20-942.59, 943.20-943.59, 944.20-944.58, 945.20-945.59, 946.2-946.5, 948.00-948.99	1 sq cm	$19.866	$18.873
Invega® Sustenna® (see Paliperidone Palmitate injection)
Isoproterenol Hydrochloride (Isuprel)	0.2 mg	$2.250	$2.138
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
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 2010: J9207
Jevtana® (see Cabazitaxel)
Kalbitor (see Ecallantide)
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	$0.109	$0.104
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	$0.076	$0.072
Lanreotide (Somatuline Depot)	1 mg			Code for 2010: J1930
Levetiracetam (Keppra intraveneous)	10 mg			Code for 2010: 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	$0.114	$0.108	(increased) Updated April 2011
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Lusedra (see Fospropofol Disodium injection)
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	$0.165	$0.157
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	$1.403	$1.333
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium	50 mg	$2.097	$1.992
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	$8.657	$8.224
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	$0.393	$0.373
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)
Ofatumumab (Arzerra) Covered indications - 204.10 or 204.12	10 mg	$45.520	$43.244	Added July 2010
Ofloxacin (Floxin IV), 20 mg		Invoice	Invoice
Olanzapine long -acting intramuscular injection Covered indications = 295.00 - 295.95 or 296.40 - 296.66 when administered in the physicians office.	1 mg	$2.809	$2.669	Added July 2010
Olanzapine short -acting intramuscular injection (Zyprexa IM) Covered indications = 295.01 - 295.84 when administered in the physicians office.	0.5 mg	$1.397	$1.327	(increased) Revised descriptor July 2010
Ontak (see Denileukin Difitox)
Optison		Invoice	Invoice
** Oxychlorosene Sodium (Clorpactin WCS-90)	1 gm	$1.850	$1.758
Ozurdex (see Dexamethasone Intravitreal Implant)
Paliperidone Palmitate injection (Invega® Sustenna®) Covered indications: 295.00-295.95, 296.40-296.46, 296.50-296.56, or 296.60-296.66	1 mg	$6.531	$6.204	Added July 2010
Panitumumab (Vectibix) Covered indications-153.0-154.8	10 mg			Code for 2010: J9303
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	$4.079	$3.875
** 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.	5 cc
Pepcid (see Famotidine)
Potassium Acetate	2 meq	$0.021	$0.020
Potassium Phosphate	3 mmol	$0.036	$0.034
Pralatrexate (Folotyn) - Covered indications: 202.70 - 202.78	1 mg	$165.625	$157.344
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Prolia ™ (see Denosumab)
Propofol (Diprivan)	10 mg	$0.073	$0.069	(increased) Updated April 2011
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
R-Gene 10 (see Arginine Hcl.)
Ranibizumab Injection (Lucentis)	1 mcg			Code for 2010: J2778
Regadenoson (Lexiscan)	0.1 mg			Code for 2010: J2785
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
Rifampin	600 mg	$38.139	$36.232
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Romidepsin (Istodax) Covered indications: 202.70 - 202.78	1 mg	$223.778	$212.589	Added July 2010
Romiplostim (Nplate™)	10 mcg			Code for 2010: J2796
Sarracenia Purpura Non-covered by Carrier
Secretin (SecreFlo) Used in secretin stimulation testing	1 mcg			Code for 2010: J2850
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sipuleucel-T (Provenge) ICD-9 = 185	250 ml Bag	$32,860.000	$31,217.000	Effective 05/01/2010
Sodium Acetate	2 meq	$0.021	$0.020	Updated October 2010
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	$0.121	$0.115	(increased) Updated April 2011
Sodium Chloride, Hypertonic	250 cc	$0.827	$0.786
** Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.158	$0.150
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)
Stelara (see Ustekinumab)
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	$0.289	$0.275
SurgiMend	0.5 sq cm	$10.650	$10.118
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 2010: 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
Tocilizumab (Actemra) Covered Indications: 714.0, 714.1 or 714.2.	1 mg	$3.519	$3.343	Added July 2010
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Treprostinil inhalation (Tyvaso) - If administered in-office, considered part of service performed. If administered at-home, not covered by Part B.	1.74 MG
Triamcinolone Acetonide, Preservative Free	1 mg			Code for 2010: J3300
Triamcinolone Acetonide (Kenalog)	10 mg			Code for 2010: J3301
Tyvaso (see Treprostinil inhalation)
Ustekinumab (Stelara) - For the treatment of adults (18+) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (696.1)	1 MG	$107.411	$102.040
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	$0.742	$0.705	(increased) Updated April 2011
Vasopressin	20 units	$1.547	$1.470	(decreased) Updated April 2011
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)	1 mg	$0.383	$0.364
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	$1.821	$1.730
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	$0.930	$0.884
Vitamin C (see Ascorbic Acid) Non-covered by Carrier**
Wilate (Human coagulation factor VIII (FVIII) and von Willebrand factor (VWF) powder and solvent for solution for injection) Covered ICD-9: 286.4	100 IU VWF:RCO	$122.070	$115.967	Added July 2010
Xiaflex (see Collagenase Clostridum Histolyticum)
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