New April 2005 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File and Revisions to January 2005 ASP Medicare Part B Drug Pricing File
Table 1
Effective January 1, 2005
HCPCS	Short Description	HCPCS Code Dosage	1Q05 Payment Limit	1Q05 Independent ESRD Limit	1Q05 Vaccine Limit	1Q05 Blood Limit
90371	Hep B ig, im	1 ML	$       115.878	$              115.878
J2790	Rho d immune globulin, inj	300 MCG	$       101.733	$              101.733
J2792	Rho (D) immune globulin, sd	100 IU	$         13.101	$               13.101
Q0187	NovoSeven	Per 1.2 MG	$     1,211.050	$           1,211.050
Table 2
Effective April 1, 2005
HCPCS	Short Description	HCPCS Code Dosage	2Q05 Payment Limit	2Q05 Independent ESRD Limit	2Q05 Vaccine Limit	2Q05 Blood Limit
90747	Hepb vacc, ill pat 4 dose im	40 MCG	$       113.915	$              113.915
J0135	Adalimumab injection	20 MG	$       294.632	$              294.632
J0287	Amphotericin b lipid complex	10 MG	$         11.724	$               11.724
J0725	Chorionic gonadotropin	1000 UNITS	$           2.976	$                 2.976
J2597	Inj desmopressin acetate	1 MCG	$           2.493	$                 2.493
J7190	Factor viii	I.U.	$           0.641	$                 0.641
J7192	Factor ix recombinant	I.U.	$           1.063	$                 1.063
J7193	Factor IX non-recombinant	I.U.	$           0.882	$                 0.882
J7194	Factor ix complex	I.U.	$           0.650	$                 0.650
J7195	Factor ix recombinant	I.U.	$           0.982	$                 0.982
J7197	Antithrombin iii injection	I.U.	$           1.543	$                 1.543
J7198	Anti-inhibitor	I.U.	$           1.241	$                 1.241
J7344	Nonmetabolic active tissue	1 SQ CM	$         52.777	$               52.777
J9098	Cytarabine liposome	10 MG	$       359.359	$              359.359
J9245	Inj melphalan hydrochl	50 MG	$       513.694	$              513.694
J9266	Pegaspargase single dose vial	1 EA	$     1,499.306	$           1,499.306
P9041	Albumin (human), 5%	50 ML	$         14.545	$               14.545		$ 14.545
P9043	Plama protein fraction, 5%	50 ML	$         14.545	$               14.545		$ 14.545
P9046	Albumin (human), 25%	20 ML	$         14.545	$               14.545		$ 14.545
P9048	Plama protein fraction, 5%	250 ML	$         29.099	$               29.099		$ 29.099
Q0187	NovoSeven	Per 1.2 MG	$     1,228.438	$           1,228.438
Q2002	Elliotts b solution per ml	1 ML	$           3.350	$                 3.350
Q2005	Corticorelin ovine triflutat	1 EA	$       379.067	$              379.067
Q2012	Pegademase bovine	25 IU	$       158.048	$              158.048
Q2018	Urofollitropin, 75 iu	75 IU	$         43.865	$               43.865
Q9941	IVIG lyophil	1 G	$         38.735	$               38.735
Q9942	IVIG lyophil	10 MG	$           0.387	$                 0.387
Q9943	IVIG non-lyophil	1 G	$         56.221	$               56.221
Q9944	IVIG non-lyophil	10 MG	$           0.562	$                 0.562
Q9954	Oral MR contrast	100 ML	$           8.844	$                 8.844
Please note J2910 is no longer included in the April 2005 pricing file.
The revised paymet limits in this notification supersede the payment limits for these codes in any
publication published prior to this document.  Note that the absence or presence of a HCPCS code and
it's associated payment limit does not indicate Medicare coverage of the drug or biological.  Similarly, the
inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in
that specific category.  The local Medicare contractor processing the claim shall make these determinations.
5/26/2005
CR 3846