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4th Quarter Update Part B Not Otherwise Classified Drug Fee Schedule — 2012 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective October 1, 2012 through December 31, 2012

Revised 07.01.13

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 2Q12 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.

Note 4: ** - Carrier Priced

Changes In Bold

Drug Name	Dosage	Current PAR	Current NON-PAR	Notes
Abatacept (Orencia) The subcutaneous form of abatacept is considered self-administered
Actemra (see Tocilizumab)
Adcetris (see Brentuximab Vedotin)
Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	$1.809	$1.719	Increase
Alglucosidase Alfa (Myozyme)	10 mg			Code for 2012: J0221
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	$328.177	$311.768	Decrease
Afinitor (see Everolimus)
Aflibercept (see EYLEA)				code for 2012 Q2046
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.049	$0.047	Decrease
Arginine Hydrochloride (R-Gene 10)	300 ml	$11.225	$10.664
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	$13.997	$13.297	Increase
** Bacitracin (Bacim)	50,000 U	$10.170	$9.662
Belimumab (Benlysta) Covered ICD-9: 710.0	10 mg			Code for 2012: J0490
Beltatacept (Nulojix) Covered indications: V420 and 075 or 996.52	250 mg.	$978.380	$929.461
Benlysta (see Belimumab)
Berinert (see C1 Esterase Inhibitor)
Bevacizumab (Avastin) CPT 67028 must be on claim or in history; allow if billed with J3490 or J3590 and the ICD-9 requirements from one of the following codes: 115.02, 115.12, 115.92, 362.01 - 362.07 (any), 362.16, 362.35 - 362.37 (any), 362.42, 362.52 or 362.83.	N/A	$60.000	$57.000	Updated ICD-9 Coverage Effective: 01/01/2011 New Unit Price Per Carrier Medical Director Effective: 05/01/2011
Brentuximab Vedotin (Adcetris) Covered indications 200.60-200.68 or 201.00-201.98	1mg	$95.400	$90.630
Bretylium Tosylate (Bretylol)	5 mg	$0.175	$0.166
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)	0.25 mg	$0.182	$0.173	Increase
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	$0.091	$0.086	Increase
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	$0.091	$0.086	Increase
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	$0.091	$0.086	Increase
Cabazitaxel (Jevtana®)	1 mg			Code for 2012: J9043
Calciferol (see Ergocalciferol D2)
Calcium Chloride	100 mg / ml	$0.159	$0.151	Decrease
Cardizem IV (see Diltiazem Hydrochloride)
Carfilzomib (Kyprolis) covered ICD-9 203.00 or 203.02	60 mg	$1,669.606		Added September 2012
** 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)	150 mg	$1.064	$1.011
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$11.704	$11.119	Increase
Clevidipine Butyrate	1 mg	$2.958	$2.810	Decrease
Clindamycin Phosphate (Cleocin)	150 mg	$2.009	$1.909	Increase
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate	0.4 mg	$0.111	$0.105	Decrease
Cystografin (see Diatrizoate Meglumine)
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
Denosumab (Prolia™ or Xgeva) If Prolia™, covered ICD-9 = 733.01; if Xgeva, covered ICD-9 = 198.5.	1 mg			Code for 2012: J0897
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
Diatrizoate Meglumine (Cystografin)	10 ml	$2.10	$2.00
Diltiazem Hydrochloride (Cardizem IV)	5 mg	$0.167	$0.159	Increase
Diprivan (see Propofol)
Doxapram Hydrochloride (Dopram)	20 mg	$2.226	$2.115	Increase
Doxycycline Hyclate	100 mg	$12.087	$11.483	Increase
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	$2.420	$2.299
Elaprase (see Idursulfase)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)	1.25 mg	$1.142	$1.085	Decrease
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
Eribulin Mesylate (Halaven) - Covered ICD-9's = 174.0 - 174.9	0.1 mg			Code for 2012: J9179
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 = 427.89 (dosage change from 100 mg to 10 mg.)	10 mg	$0.778	$0.739	Increase
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.	20 MG	$1.904	$1.809	Decrease
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	$0.699	$0.664	Increase
Everolimus (Afinitor / Zortress) - Non-Covered; Oral drug considered as self-administered.				Code for 2012: J8561
EYLEA (see Aflibercept)
Famotidine (Pepcid)	10 mg	$0.498	$0.473	Increase
Firazyr (see Icantibant)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)	0.1 mg	$2.005	$1.905	Increase
Flumazenil (Mazicon, Romazicon)	0.5 mg	$42.830	$40.689
Folic Acid	5 mg	$2.179	$2.070	Increase
Folotyn (see Pralatrexate)
Fospropofol Disodium injection (Lusedra)	35 mg	$1.048	$0.996	Increase
Gammaked injection	500 mg	$37.484	$35.610
Gammaplex (see Human Immune Globulin Intravenous)
Glycopyrrolate (Robinul)	0.2 mg	$0.614	$0.583	Increase
Halaven (see Eribulin Mesylate)
** Heparin Sodium	100 units	$0.032	$0.030
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm	$23.040	$21.888
Hexaminolevulinate Hydrochloride - Covered for ICD-9's 188.0 through 188.9	100 mg, per study dose	$660.677	$627.643	Increase
Hizentra (see Immune Globulin Subcutaneous)
Human Immune Globulin Intravenous (Gammaplex)	IV			Code for 2012: J1557
Hydroxocobalamin - Covered when billed with J9305.	1000 mcg/ml	$1.212	$1.151
Icantibant (Firazyr) - Usually considered self-administered
Ilaris (see Canakinumab)
** Inamrinone Lactate	5 mg	$4.050	$3.848
IncobotulinumtoxinA (Xeomin) - Covered for the treatment of Genetic torsion dystonia (333.6) and Blepharospasm (333.81)	1 Unit			New Code for 2012: J0588
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	$24.147	$22.940	Increase
Invega® Sustenna® (see Paliperidone Palmitate injection)
Ipilimumab (Yervoy) - Covered for unresectable or metastatic melanoma.	1mg			Code for 2012: J9228
Isoproterenol Hydrochloride (Isuprel)	0.2 mg	$2.250	$2.138
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
Isuprel (see Isoproterenol Hydrochloride)
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	$0.067	$0.064
Kyprolis (see Carfilzomib)				Added September 2012
Krystexxa (see Pegloticase)
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	$1.091	$1.036	Decrease
** 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	$0.143	$0.136
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Lusedra (see Fospropofol Disodium injection)
Mandol (see Cefamanadole Nafate)
Marqibo (see Vincristine sulfate Liposome)
Mazicon (see Flumazenil)				Added September 2012
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	$0.163	$0.155	Increase
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	$1.069	$1.016	Increase
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)				Code for 2012: J2265
Monistat IV (see Miconazole)
Morrhuate Sodium	50 mg	$2.105	$2.000
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (dosage Change from 500 mg to 1 gm)	1 gm	$8.058	$7.655
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	Increase
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)
Nulojix (see Beltatacept)
Ofloxacin (Floxin IV), 20 mg		Invoice	Invoice
*Olanzapine short-acting intramuscular injection (Zyprexa IM) Covered indications = 295.01 - 295.84 when administered in the physicians office.*	0.5 mg	$1.705	$1.620	Increase
Ontak (see Denileukin Difitox)
Optison		Invoice	Invoice
Orencia (see Abatacept)
** Oxychlorosene Sodium (Clorpactin WCS-90)	1 gm	$1.850	$1.758
Ozurdex (see Dexamethasone Intravitreal Implant)
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	$4.511	$4.285
** 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
Pegloticase (Krystexxa) When billed with J3490 or J3590, covered for chronic gout, ICD-9's 274.00 through 274.03	1mg			Code for 2012: J2507
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered
Pepcid (see Famotidine)
Perjeta (see Pertuzumab)				Added September 2012
Pertuzumab (Perjeta) Covered ICD-9 174.0 - 175.9 in combination with Trastuzumab J9355 and Docetaxel J9171	1mg/ml	$9.704	$9.219	Added September 2012
Potassium Acetate	2 meq	$0.027	$0.026
Potassium Phosphate	3 mmol	$0.043	$0.041
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Prolia™ (see Denosumab)
Propofol (Diprivan)	10 mg	$0.103	$0.098
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
** R-Gene 10 (see Arginine Hcl.)
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate Human)
Rifampin	600 mg	$32.776	$31.137	Increase
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Sarracenia Purpura Non-covered by Carrier
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sipuleucel-T (Provenge) ICD-9 = 185	Per infusion (minimum 50 million cells)			New Code for 2012: Q2043
Sodium Acetate	2 meq	$0.031	$0.029	Decrease
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	$0.122	$0.116
Sodium Chloride, Hypertonic	250 cc	$0.708	$0.673	Increase
** Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.155	$0.147
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)	5 cc	$0.052	$0.049
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	$0.276	$0.262	Increase
SurgiMend	0.5 sq cm	$12.026	$11.425	Increase
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
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)
Truxton (see Prednisolone Acetate)
Tyvaso (see Treprostinil inhalation)
Vaccinia IVIG (see Human Immune Globulin Intravenous)
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	$0.558	$0.530
Vasopressin	20 units	$2.310	$2.195	Increase
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)	1 mg	$0.499	$0.474	Decrease
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	$3.167	$3.009
VIBATIV™ (see Telavancin Injection)
Vincristine Sulfate Liposome (Marquibo) covered ICD-9: 204.00-204.02	2.25 mg.	Invoice		Added September 2012
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3 ml	$0.930	$0.884
** Vitamin C (see Ascorbic Acid) Non-covered by Carrier
Vivaglobin (see Immune Globulin Subcutaneous)
VPRIV™ (see Velaglucerase alfa for injection)
Wilate (Human coagulation factor VIII (FVIII) and von Willebrand factor (VWF) powder and solvent for solution for injection) Covered ICD-9: 286.4	1 IU VWF:RCO			New Code for 2012: J7183
Xeomin (see IncobotulinumtoxinA)
Xgeva (see Denosumab)
Xiaflex (see Collagenase Clostridum Histolyticum)
Xyntha (see Antihemophilic Factor (Recomb) Plasma/Albumin-Free)
Yervoy (see Ipilimumab)
Zaltrap (see Ziv-Aflibercept)				Added September 2012
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 - 153.7 or 154.0 - 154.2	100 mg.	$1,611.200		Added September 2012
Zortress (see Everolimus)
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

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