Jurisdiction A DME MAC Fee Schedules
1st Quarter 2009 Oral Anti-Cancer Drug Fees
Effective January 1, 2009 through March 31, 2009
NOTE: Inclusion of a fee amount does not
necessarily indicate coverage
|
Drug Name |
Strength |
Per Tablet Fee |
|
Busulfan |
2 mg |
$2.912 |
|
Capecitabine |
150 mg |
$5.225 |
|
Capecitabine |
500 mg |
$17.418 |
|
Cyclophosphamide |
25 mg |
$0.924 |
|
Cyclophosphamide |
50 mg |
$1.848 |
|
Etoposide |
50 mg |
$29.572 |
|
Melphalan |
2 mg |
$4.505 |
|
Methotrexate |
2.5 mg |
$0.162 |
|
Methotrexate |
5 mg |
$0.324 |
|
Methotrexate |
7.5 mg |
$0.486 |
|
Methotrexate |
10 mg |
$0.648 |
|
Methotrexate |
15 mg |
$0.972 |
|
Temozolomide |
5 mg |
$8.250 |
|
Temozolomide |
20 mg |
$33.000 |
|
Temozolomide |
100 mg |
$165.000 |
|
Temozolomide |
250 mg |
$412.500 |