Payment Allowance Limits for Medicare Part B Drugs
                 
Effective January 1, 2006 through March 31, 2006
                     
Note 1: Payment allowance limits subject to the ASP methodology are based on 3Q05 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 $118.235              
90375 Rabies ig, im/sc 150 IU $64.905              
90376 Rabies ig, heat treated 150 IU $68.914              
90385 Rh ig, minidose, im 50 MCG $6.613              
90396 Varicella-zoster ig, im 125 UNITS $110.411              
90585 Bcg vaccine, percut 50 MG $118.161              
90586 Bcg vaccine, intravesical 1 EACH $115.087              
90632 Hep a vaccine, adult im 1 ML $42.184              
90633 Hep a vacc, ped/adol, 2 dose 1 ML $22.644              
90634 Hep a vacc, ped/adol, 3 dose 3 EACH $22.652              
90645 Hib vaccine, hboc, im 1 EACH $21.520              
90647 Hib vaccine, prp-omp, im 0.5 ML $21.520              
90648 Hib vaccine, prp-t, im 0.5 ML $21.782              
90655 Flu Vaccine 0.25 ML $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          
90675 Rabies vaccine, im 1 ML $147.203              
90691 Typhoid vaccine, im 0.5 ML $37.519              
90700 Dtap vaccine, < 7 yrs, im 0.5 ML $22.642              
90702 Dt vaccine < 7, im 0.5 ML $17.500              
90703 Tetanus vaccine, im 0.5 ML $21.424              
90704 Mumps vaccine, sc 0.5 ML $19.145              
90705 Measles vaccine, sc 0.5 ML $14.493              
90706 Rubella vaccine, sc 0.5 ML $16.165              
90707 Mmr vaccine, sc 0.5 ML $38.505              
90713 Poliovirus, ipv, sc/im 0.5 ML $25.009              
90716 Chicken pox vaccine, sc 0.5 ML $67.342              
90717 Yellow fever vaccine, sc 0.5 ML $59.460              
90721 Dtap/hib vaccine, im 1 EACH $41.724              
90732 Pneumococcal vaccine 0.5 ML $24.571 95% $24.571          
90733 Meningococcal vaccine, sc 0.5 ML $86.100              
90735 Encephalitis vaccine, sc 1 ML $88.127              
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 $67.928 95% $67.928          
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 $67.394              
J0130 Abciximab injection 10 MG $525.993              
J0132 Acetylcysteine injection 100 MG 1.868             revised 04/01/2006
J0133 Acyclovir injection 5 MG $0.025              
J0135 Adalimumab injection 20 MG $301.766              
J0150 Injection adenosine 6 MG 6 MG $32.568              
J0152 Adenosine injection 30 MG $70.298              
J0170 Adrenalin epinephrin inject 1 ML $0.599              
J0180 Agalsidase beta injection 1 MG $127.200              
J0205 Alglucerase injection 10 UNITS $39.220              
J0207 AMIfostine 500 MG $442.331              
J0210 Methyldopate hcl injection 250 MG $9.986              
J0215 Alefacept 0.5 MG $26.506              
J0256 Alpha 1 proteinase inhibitor 10 MG $3.233              
J0270 Alprostadil for injection 1.25 MCG $1.823              
J0275 Alprostadil urethral suppos 125 MCG $21.661              
J0278 Amikacin sulfate injection 100 MG $1.304             corrected code dosage
J0280 Aminophyllin 250 MG inj 250 MG $0.395              
J0282 Amiodarone HCl 30 MG $0.325              
J0285 Amphotericin B 50 MG $7.618     95% $10.280      
J0287 Amphotericin b lipid complex 10 MG $11.272     95% $21.850      
J0288 Ampho b cholesteryl sulfate 10 MG $12.000     95% $15.200      
J0289 Amphotericin b liposome inj 10 MG $19.031     95% $35.800      
J0290 Ampicillin 500 MG inj 500 MG $2.458              
J0295 Ampicillin sodium per 1.5 gm 1.5 GM $6.504              
J0300 Amobarbital 125 MG inj 125 MG $2.427              
J0330 Succinycholine chloride inj 20 MG $0.137              
J0350 Injection anistreplase 30 u 30 UNITS $2,268.460              
J0360 Hydralazine hcl injection 20 MG $6.088              
J0365 Aprotonin, 10,000 kiu 10000 KIU $2.333              
J0456 Azithromycin 500 MG $24.887              
J0460 Atropine sulfate injection 0.3 MG $0.398              
J0470 Dimecaprol injection 100 MG $21.802              
J0475 Baclofen 10 MG injection 10 MG $191.118     95% $215.180      
J0476 Baclofen intrathecal trial 50 MCG $71.002     95% $79.800      
J0480 Basiliximab 20 MG $1,410.893              
J0500 Dicyclomine injection 20 MG $15.956              
J0515 Inj benztropine mesylate 1 MG $3.873              
J0530 Penicillin g benzathine inj 600000 UNITS $13.189              
J0540 Penicillin g benzathine inj 1200000 UNITS $25.584              
J0550 Penicillin g benzathine inj 2400000 UNITS $33.479              
J0560 Penicillin g benzathine inj 600000 UNITS $19.545              
J0570 Penicillin g benzathine inj 1200000 UNITS $33.837              
J0580 Penicillin g benzathine inj 2400000 UNITS $65.719              
J0583 Bivalirudin 1 MG $1.623              
J0585 Botulinum toxin a per unit 1 UNIT $4.906              
J0587 Botulinum toxin type B 100 UNITS $7.821              
J0592 Buprenorphine hydrochloride 0.1 MG $0.751              
J0595 Butorphanol tartrate 1 mg 1 MG $0.767              
J0600 Edetate calcium disodium inj 1000 MG $39.934             corrected code dosage
J0610 Calcium gluconate injection 10 ML $0.404              
J0630 Calcitonin salmon injection 400 UNITS $37.810              
J0636 Inj calcitriol per 0.1 mcg 0.1 MCG $0.705              
J0637 Caspofungin acetate 5 MG $32.462              
J0640 Leucovorin calcium injection 50 MG $1.277              
J0670 Inj mepivacaine HCL/10 ml 10 ML $1.309              
J0690 Cefazolin sodium injection 500 MG $1.383              
J0692 Cefepime HCl for injection 500 MG $7.554