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2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule — 2013 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective April 1, 2013 through June 30, 2013

Revised: 05.09.14

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	NDC Number	DOSAGE	Current PAR	Current NON-PAR	Notes
Ado-Trastuzumab Emtansine (Kadcyla) covered indications HER2-positive, metastatic breast cancer (174.0-175.9)		10 mgs.	$293.998	$279.298	Added March 2013
Alfentanil Hydrochloride (Alfenta)		500 mcg/5 ml	$1.887	$1.793
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	$303.245	$288.083
Afinitor (see Everolimus)
Amidate (see Etomidate)
Amino Acid		500 ml	$21.110	$20.055
Amino Acid		1000 ml	$35.190	$33.431
Aminocaproic Acid		250 mg	$0.081	$0.077
Arginine Hydrochloride (R-Gene 10)		300 ml	$11.225	$10.664
Arzerra (see Ofatumumab)
** Ascorbic Acid (Vitamin C) (Cenolate) 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	$13.804	$13.114
** Bacitracin (Bacim)		50,000 U	$10.170	$9.662
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
Bivigam	59730-6503-01	500 mg	$63.579	$60.400	added June 2013
Bivigam	59730-6502-01	500 mg	$63.579	$60.400	added June 2013
Bretylium Tosylate (Bretylol)		5 mg	$0.175	$0.166
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)		0.25 mg	$0.215	$0.204
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	$0.087	$0.083
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	$0.087	$0.083
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	$0.087	$0.083
Calciferol (see Ergocalciferol D2)
Calcium Chloride		100 mg / ml	$0.159	$0.151
Candida Antigen Non covered by carrier
Cardizem IV (see Diltiazem Hydrochloride)
Carfilzomib (Kyprolis) covered ICD-9 203.00 or 203.02		1 mg	$29.291	$27.826	Updated April 2013
** 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
Cenolate (Vitamin C) (Ascorbic Acid) Non covered by carrier
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	$10.790	$10.251
Clevidipine Butyrate		1 mg	$2.873	$2.729
Clindamycin Phosphate (Cleocin)		150 mg	$1.822	$1.731
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate		0.4 mg	$0.125	$0.119
Cystografin (see Diatrizoate Meglumine)
Dantrolene Sodium		20 mg	$78.800	$74.860
Depacon (see Valproate Sodium)
Depakene Non covered by carrier
Depakote Non covered by carrier
Depakote ER Non covered by carrier
Depakote Sprinkles Non covered by carrier
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
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	$0.212	$0.201
Diprivan (see Propofol)
Divalproex Sodium Non covered by carrier
Divalproex Sodium ER Non covered by carrier
Doxapram Hydrochloride (Dopram)		20 mg	$2.195	$2.085
Doxycycline Hyclate		100 mg	$12.774	$12.135
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
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	$0.781	$0.742
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.		20 MG	$2.422	$2.301
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	$0.655	$0.622
EYLEA (see Aflibercept)
Famotidine (Pepcid)		10 mg	$0.366	$0.348
Firazyr (see Icantibant)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)		0.1 mg	$1.039	$0.987
Flumazenil (Mazicon, Romazicon)		0.5 mg	$42.830	$40.689
Folic Acid		5 mg	$2.276	$2.162
Folotyn (see Pralatrexate)
Fospropofol Disodium injection (Lusedra)		35 mg	$1.272	$1.208
Gammaked injection		500 mg	$37.484	$35.610
Gammaplex (see Human Immune Globulin Intravenous)
Glucarpidase		10 units	$233.730	$222.044
Glycopyrrolate (Robinul)		0.2 mg	$0.622	$0.591
Halaven (see Eribulin Mesylate)
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	$741.576	$704.497
Hizentra (see Immune Globulin Subcutaneous)
Hydroxocobalamin - Covered when billed with J9305.		1000 mcg/ml	$1.212	$1.151
Icantibant (Firazyr) - Usually considered self-administered
Ilaris (see Canakinumab)
Immune Globulin (see Bivigam)	59730-6503-01	100 ml			added June 2013
Immune Globulin (see Bivigam)	59730-6502-01	50 ml			added June 2013
** Inamrinone Lactate		5 mg	$4.050	$3.848
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)
Jetrea (Ocriplasmin) Covered indication 379.27 (vitreomacular adhesion)		0.2 ml SDV	$4,187.000	$3,977.650
Jevtana® (see Cabazitaxel)
Kadcyla (see Ado-Trastuzumab Emtansine)					Added March 2013
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)
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	$0.211	$0.200
** 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
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)
Lusedra (see Fospropofol Disodium injection)
Magnesium Chloride Hexahydrate-Covered for the correction of hypomagnesemia (275.2) – 1 gram equals 1 unit/number of service when administered in the physician’s office "		1 gram	$0.328	$0.311
Mandol (see Cefamanadole Nafate)
Marqibo (see Vincristine sulfate Liposome)
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	$0.270	$0.257
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	$1.128	$1.072
Miconazole (Monistat IV) 10 mg			Invoice	Invoice
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	$0.362	$0.344
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)
Ocriplasmin Intraviteral Injection (see Jetrea)
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	$1.598	$1.518
Omacetaxine Mepesuccinate (Synribo) covered indications 205.10 without having achieved remission, failed remission or 205.12 in relapse		3.5 mg	$885.100	$840.845
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
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered
Pepcid (see Famotidine)
Perjeta (see Pertuzumab)
Pertuzumab (Perjeta) Covered ICD-9 174.0 - 175.9 in combination with Trastuzumab J9355 and Docetaxel J9171		10 mg/ml	$102.269	$97.156
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	$0.123	$0.117
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
** R-Gene 10 (see Arginine Hcl.)
Radium Ra 223 dichloride (Xofigo), A9699 – Approved FDA indications of castration-resistant prostate cancer (185) plus symptomatic bone metastases (198.5 secondary malignant neoplasm of bone and bone marrow). The patient’s records should contain documentation regarding no known visceral metastatic disease		PER TREATMENT DOSE	$12,190.000	$11,580.500	Updated 05/2014
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate Human)
Rifampin		600 mg	$38.934	$36.987
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Sarracenia Purpura Non-covered by Carrier
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sodium Acetate		2 meq	$0.043	$0.041
** 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	$0.703	$0.668
Sodium Hyaluronate/Chondroitin Sulfate (Viscoat) Non covered by carrier
** 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
Stavzor Non covered by carrier
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	$0.311	$0.295
SurgiMend		0.5 sq cm	$11.885	$11.291
Synribo (see Omacetaxine Mepesuccinate)
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
Taliglucurase Alfa		10 units	$30.904
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)
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
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)
Valproic Acid Non covered by carrier
Vasopressin		20 units	$1.214	$1.153
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)		1 mg	$0.433	$0.411
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
Viscoat (Sodium Hyaluronate/Chondroitin Sulfate) Non covered by carrier
** Vitamin B Complex		Up to 3 ml	$0.930	$0.884
** Vitamin C (see Ascorbic Acid) (Cenolate) 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
Xeomin (see IncobotulinumtoxinA)
Xgeva (see Denosumab)
Xiaflex (see Collagenase Clostridum Histolyticum)
Xofigo (see Radium Ra 223 dichloride)
Xyntha (see Antihemophilic Factor (Recomb) Plasma/Albumin-Free)
Yervoy (see Ipilimumab)
Zaltrap (see Ziv-Aflibercept)
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 - 153.7 or 154.0 - 154.2		1 mg.	$15.572		Updated April 2013
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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