Jurisdiction A DME MAC Fee Schedules
October 2007 Oral Anti-Cancer Drug Fees
Effective October 1, 2007 through December 31, 2007
NOTE:
Inclusion of a fee amount does not necessarily indicate coverage
|
Drug Name |
Strength |
Per Tablet Fee |
|
Busulfan |
2 mg |
$2.282 |
|
Capecitabine |
150 mg |
$4.323 |
|
Capecitabine |
500 mg |
$14.324 |
|
Cyclophosphamide |
25 mg |
$0.965 |
|
Cyclophosphamide |
50 mg |
$1.930 |
|
Etoposide |
50 mg |
$29.741 |
|
Melphalan |
2 mg |
$4.336 |
|
Methotrexate |
2.5 mg |
$0.234 |
|
Methotrexate |
5 mg |
$0.468 |
|
Methotrexate |
7.5 mg |
$0.702 |
|
Methotrexate |
10 mg |
$0.936 |
|
Methotrexate |
15 mg |
$1.404 |
|
Temozolomide |
5 mg |
$7.563 |
|
Temozolomide |
20 mg |
$30.252 |
|
Temozolomide |
100 mg |
$151.260 |
|
Temozolomide |
250 mg |
$378.150 |