Payment Allowance Limits for Medicare Part B Drugs
                     
Effective April 1, 2006 through June 30, 2006
                     
Note 1: Payment allowance limits subject to the ASP methodology are based on 4Q05 ASP data.                     
Note 2: 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. 
                     
HCPCS Code Short Description HCPCS Code Dosage Payment Limit Vaccine AWP% Vaccine Limit Infusion AWP% DME Infusion Limit Blood AWP% Blood Limit Notes
90371 Hep b ig, im 1 ML $119.736              
90375 Rabies ig, im/sc 150 IU $64.591              
90376 Rabies ig, heat treated 150 IU $69.231              
90385 Rh ig, minidose, im 50 MCG $4.928              
90585 Bcg vaccine, percut 50 MG $116.558              
90586 Bcg vaccine, intravesical 1 EACH $111.537              
90632 Hep a vaccine, adult im 1 ML $46.827              
90633 Hep a vacc, ped/adol, 2 dose 1 ML $23.829              
90634 Hep a vacc, ped/adol, 3 dose 3 EACH $23.855              
90645 Hib vaccine, hboc, im 1 EACH $21.524              
90647 Hib vaccine, prp-omp, im 0.5 ML $21.524              
90648 Hib vaccine, prp-t, im 0.5 ML $21.782              
90655 Flu vaccine no preserv 6-35m 0.25 ML $14.678 95% $14.678          
90656 Flu vaccine no preserv 3 & > 0.50 ML $15.818 95% $15.818          
90657 Flu vaccine, 6-35 mo, im 0.25 ML $6.028 95% $6.028          
90658 Flu vaccine age 3 & over, im 0.5 ML $12.056 95% $12.056          
90660 Flu vaccine, nasal 0.5 ML $21.176 95% $21.176          
90675 Rabies vaccine, im 1 ML $156.732              
90691 Typhoid vaccine, im 0.5 ML $50.679              
90700 Dtap vaccine, < 7 yrs, im 0.5 ML $23.466              
90702 Dt vaccine < 7, im 0.5 ML $18.300              
90703 Tetanus vaccine, im 0.5 ML $18.337              
90704 Mumps vaccine, sc 0.5 ML $19.144              
90705 Measles vaccine, sc 0.5 ML $14.518              
90706 Rubella vaccine, sc 0.5 ML $16.161              
90707 Mmr vaccine, sc 0.5 ML $38.586              
90713 Poliovirus, ipv, sc/im 0.5 ML $24.888              
90714 Td vaccine no prsrv >/= 7 im 0.5 ML $18.266              
90716 Chicken pox vaccine, sc 0.5 ML $67.475              
90717 Yellow fever vaccine, sc 0.5 ML $54.440              
90718 Td vaccine > 7, im 0.5 ML $18.266              
90721 Dtap/hib vaccine, im 1 EACH $41.724              
90732 Pneumococcal vaccine 0.5 ML $27.028 95% $27.028          
90733 Meningococcal vaccine, sc 0.5 ML $84.460              
90735 Encephalitis vaccine, sc 1 ML $100.099              
90740 Hepb vacc, ill pat 3 dose im 40 MCG $113.914 95% $113.914          
90743 Hep b vacc, adol, 2 dose, im 10 MCG $57.551 95% $57.551          
90744 Hepb vacc ped/adol 3 dose im 1 DOSE $68.381 95% $68.381          
90746 Hep b vaccine, adult, im 1 EACH $56.957 95% $56.957          
90747 Hepb vacc, ill pat 4 dose im 40 MCG $113.914 95% $113.914          
J0128 Abarelix injection 10 MG $66.833              
J0130 Abciximab injection 10 MG $457.273              
J0132 Acetylcysteine injection 100 MG $1.874              
J0133 Acyclovir injection 5 MG $0.026              
J0135 Adalimumab injection 20 MG $307.302              
J0150 Injection adenosine 6 MG 6 MG $30.189              
J0152 Adenosine injection 30 MG $70.071              
J0170 Adrenalin epinephrin inject 1 ML $0.570              
J0180 Agalsidase beta injection 1 MG $127.200              
J0205 Alglucerase injection 10 UNITS $39.220              
J0207 Amifostine 500 MG $452.684              
J0210 Methyldopate hcl injection 250 MG $9.950              
J0215 Alefacept 0.5 MG $26.153             revised 7/1/06
J0256 Alpha 1 proteinase inhibitor 10 MG $3.242              
J0270 Alprostadil for injection 1.25 MCG $1.815              
J0275 Alprostadil urethral suppos 125 MCG $21.995              
J0278 Amikacin sulfate injection 100 MG $1.309             revised 7/1/06
J0280 Aminophyllin 250 MG inj 250 MG $0.414              
J0282 Amiodarone HCl 30 MG $0.193              
J0285 Amphotericin B 50 MG $8.879     95% $10.280     revised 7/1/06
J0287 Amphotericin b lipid complex 10 MG $11.205     95% $21.850      
J0288 Ampho b cholesteryl sulfate 10 MG $12.000     95% $15.200      
J0289 Amphotericin b liposome inj 10 MG $17.566     95% $35.800      
J0290 Ampicillin 500 MG inj 500 MG $1.888             revised 7/1/06
J0295 Ampicillin sodium per 1.5 gm 1.5 GM $4.518              
J0300 Amobarbital 125 MG inj 125 MG $2.145              
J0330 Succinycholine chloride inj 20 MG $0.140              
J0350 Injection anistreplase 30 u 30 UNITS $2,265.460              
J0360 Hydralazine hcl injection 20 MG $5.106              
J0365 Aprotonin, 10,000 kiu 10000 KIU $2.347              
J0456 Azithromycin 500 MG $25.324              
J0460 Atropine sulfate injection 0.3 MG $0.227              
J0470 Dimecaprol injection 100 MG $21.834              
J0475 Baclofen 10 MG injection 10 MG $193.322     95% $215.180      
J0476 Baclofen intrathecal trial 50 MCG $70.872     95% $79.800      
J0480 Basiliximab 20 MG $1,402.038              
J0500 Dicyclomine injection 20 MG $15.112              
J0515 Inj benztropine mesylate 1 MG $4.774              
J0530 Penicillin g benzathine inj 600000 UNITS $13.069              
J0540 Penicillin g benzathine inj 1200000 UNITS $25.889              
J0550 Penicillin g benzathine inj 2400000 UNITS $32.597              
J0560 Penicillin g benzathine inj 600000 UNITS $19.463              
J0570 Penicillin g benzathine inj 1200000 UNITS $33.827              
J0580 Penicillin g benzathine inj 2400000 UNITS $68.507              
J0583 Bivalirudin 1 MG $1.635              
J0585 Botulinum toxin a per unit 1 UNIT $4.901              
J0587 Botulinum toxin type B 100 UNITS $7.929              
J0592 Buprenorphine hydrochloride 0.1 MG $0.747              
J0595 Butorphanol tartrate 1 mg 1 MG $0.839              
J0600 Edetate calcium disodium inj 1000 MG $40.179              
J0610 Calcium gluconate injection 10 ML $0.545              
J0630 Calcitonin salmon injection 400 UNITS $37.810              
J0636 Inj calcitriol per 0.1 mcg 0.1 MCG $0.462              
J0637 Caspofungin acetate 5 MG $32.496              
J0640 Leucovorin calcium injection 50 MG $0.913              
J0670 Inj mepivacaine HCL/10 ml 10 ML $1.363             revised 7/1/06
J0690 Cefazolin sodium injection 500 MG $1.287             revised 7/1/06
J0692 Cefepime HCl for injection 500 MG $7.818              
J0694 Cefoxitin sodium injection 1 GM $7.516              
J0696 Ceftriaxone sodium injection 250 MG $4.187             revised 7/1/06
J0697 Sterile cefuroxime injection 750 MG $1.770              
J0698 Cefotaxime sodium injection 1 GM $4.317              
J0702 Betamethasone acet&sod phosp 3 MG $5.068              
J0704 Betamethasone sod phosp/4 MG 4 MG $0.907              
J0706 Caffeine citrate injection 5 MG $3.369              
J0713 Inj ceftazidime per 500 mg 500 MG $4.073              
J0715 Ceftizoxime sodium / 500 MG 500 MG $3.559              
J0720 Chloramphenicol sodium injec 1 GM $12.039              
J0725 Chorionic gonadotropin/1000u 1000 UNITS $3.132              
J0735 Clonidine hydrochloride 1 MG $63.311              
J0740 Cidofovir injection 375 MG $764.239              
J0743 Cilastatin sodium injection 250 MG $13.205              
J0744 Ciprofloxacin iv 200 MG $8.320              
J0745 Inj codeine phosphate /30 MG 30 MG $0.950              
J0760 Colchicine injection 1 MG $4.543              
J0770 Colistimethate sodium inj 150 MG $25.080              
J0780 Prochlorperazine injection 10 MG $2.284              
J0795 Corticorelin ovine triflutal 1 MCG $4.260              
J0800 Corticotropin injection 40 UNITS $109.884              
J0835 Inj cosyntropin per 0.25 MG 0.25 MG $64.155              
J0850 Cytomegalovirus imm IV /vial PER VIAL $762.988              
J0878 Daptomycin injection 1 MG $0.313              
J0881 Darbepoetin alfa, non-esrd 1 MCG $3.033              
J0882 Darbepoetin alfa, esrd use 1 MCG $3.033              
J0885 Epoetin alfa, non-esrd 1000 UNITS $9.339              
J0886 Epoetin alfa, esrd 1000 UNITS $9.334              
J0895 Deferoxamine mesylate inj 500 MG $14.912     95% $15.630      
J0900 Testosterone enanthate inj 1 CC $1.379              
J0945 Brompheniramine maleate inj 10 MG $0.732              
J0970 Estradiol valerate injection 40 MG $32.524              
J1000 Depo-estradiol cypionate inj 5 MG $5.303              
J1020 Methylprednisolone 20 MG inj 20 MG $2.803              
J1030 Methylprednisolone 40 MG inj 40 MG $5.231              
J1040 Methylprednisolone 80 MG inj 80 MG $9.421              
J1051 Medroxyprogesterone inj 50 MG $5.234              
J1056 MA/EC contraceptiveinjection 5 MG $22.885              
J1060 Testosterone cypionate 1 ML 1 ML $4.142              
J1070 Testosterone cypionat 100 MG 100 MG $5.156              
J1080 Testosterone cypionat 200 MG 200 MG $12.517              
J1094 Inj dexamethasone acetate 1 MG $0.230              
J1100 Dexamethasone sodium phos 1 MG $0.127              
J1110 Inj dihydroergotamine mesylt 1 MG $25.271              
J1120 Acetazolamid sodium injectio 500 MG $14.946              
J1160 Digoxin injection 0.5 MG $1.034              
J1162 Digoxin immune fab (ovine) PER VIAL $532.483              
J1165 Phenytoin sodium injection 50 MG $0.844              
J1170 Hydromorphone injection 4 MG $1.765     95% $1.490      
J1180 Dyphylline injection 500 MG $8.045              
J1190 Dexrazoxane HCl injection 250 MG $181.330              
J1200 Diphenhydramine hcl injectio 50 MG $0.791              
J1205 Chlorothiazide sodium inj 500 MG $12.815              
J1212 Dimethyl sulfoxide 50% 50 ML 50 ML $42.103              
J1230 Methadone injection 10 MG $3.485     95% $0.750      
J1240 Dimenhydrinate injection 50 MG $3.779              
J1245 Dipyridamole injection 10 MG $1.706              
J1250 Inj dobutamine HCL/250 mg 250 MG $4.779     95% $4.740      
J1260 Dolasetron mesylate 10 MG $6.824              
J1265 Dopamine injection 40 MG $0.729              
J1270 Injection, doxercalciferol 1 MCG $3.167              
J1320 Amitriptyline injection 20 MG $2.237              
J1325 Epoprostenol injection 0.5 MG $13.200     95% $12.640      
J1327 Eptifibatide injection 5 MG $13.440              
J1335 Ertapenem injection 500 MG $23.172              
J1364 Erythro lactobionate /500 MG 500 MG $5.602              
J1380 Estradiol valerate 10 MG inj 10 MG $11.974              
J1390 Estradiol valerate 20 MG inj 20 MG $16.262              
J1410 Inj estrogen conjugate 25 MG 25 MG $58.332              
J1430 Ethanolamine oleate 100 mg 100 MG $72.252              
J1435 Injection estrone per 1 MG 1 MG $0.138              
J1436 Etidronate disodium inj 300 MG $71.407              
J1438 Etanercept injection 25 MG $155.584              
J1440 Filgrastim 300 mcg injection 300 MCG $184.266              
J1441 Filgrastim 480 mcg injection 480 MCG $292.346              
J1450 Fluconazole 200 MG $11.853              
J1451 Fomepizole, 15 mg 15 MG $11.933              
J1452 Intraocular Fomivirsen na 1.65 MG $212.000              
J1455 Foscarnet sodium injection 1000 MG $10.794     95% $13.070     revised 7/1/06
J1457 Gallium nitrate injection 1 MG $1.247              
J1460 Gamma globulin 1 CC inj 1 CC $10.686              
J1470