Payment Allowance Limits for Medicare Part B Drugs
Effective October 1, 2006 through December 31, 2006
Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q06 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	$113.271							Revised 01/01/07
90375	Rabies ig, im/sc	150 IU	$64.526
90376	Rabies ig, heat treated	150 IU	$68.236
90385	Rh ig, minidose, im	50 MCG	$7.308
90585	Bcg vaccine, percut	50 MG	$117.391
90586	Bcg vaccine, intravesical	1 EACH	$113.435
90632	Hep a vaccine, adult im	1 ML	$43.289							Revised 01/01/07
90633	Hep a vacc, ped/adol, 2 dose	1 ML	$23.634							Revised 01/01/07
90634	Hep a vacc, ped/adol, 3 dose	3 EACH	$23.634							Revised 01/01/07
90645	Hib vaccine, hboc, im	1 EACH	$21.268
90647	Hib vaccine, prp-omp, im	0.5 ML	$21.268
90648	Hib vaccine, prp-t, im	0.5 ML	$21.782
90655	Flu vaccine no preserv 6-35m	0.25 ML	$15.377	95%	$15.377
90656	Flu vaccine no preserv 3 & >	0.50 ML	$16.574	95%	$16.574
90657	Flu vaccine, 6-35 mo, im	0.25 ML	$6.312	95%	$6.312
90658	Flu vaccine age 3 & over, im	0.5 ML	$12.624	95%	$12.624
90660	Flu vaccine, nasal	0.5 ML	$21.176	95%	$21.176
90675	Rabies vaccine, im	1 ML	$157.737
90691	Typhoid vaccine, im	0.5 ML	$52.053
90700	Dtap vaccine, < 7 yrs, im	0.5 ML	$29.401
90702	Dt vaccine < 7, im	0.5 ML	$18.300
90703	Tetanus vaccine, im	0.5 ML	$19.378
90704	Mumps vaccine, sc	0.5 ML	$20.379							Revised 01/01/07
90705	Measles vaccine, sc	0.5 ML	$15.542							Revised 01/01/07
90706	Rubella vaccine, sc	0.5 ML	$17.194							Revised 01/01/07
90707	Mmr vaccine, sc	0.5 ML	$40.999
90713	Poliovirus, ipv, sc/im	0.5 ML	$26.005
90714	Td vaccine no prsrv >/= 7 im	0.5 ML	$18.778
90716	Chicken pox vaccine, sc	0.5 ML	$72.280							Revised 01/01/07
90717	Yellow fever vaccine, sc	0.5 ML	$54.440
90718	Td vaccine > 7, im	0.5 ML	$18.828
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	$96.220
90740	Hepb vacc, ill pat 3 dose im	40 MCG	$114.521	95%	$114.521
90743	Hep b vacc, adol, 2 dose, im	1 DOSE	$24.358	95%	$24.358
90744	Hepb vacc ped/adol 3 dose im	1 DOSE	$24.358	95%	$24.358
90746	Hep b vaccine, adult, im	20 MCG	$57.260	95%	$57.260
90747	Hepb vacc, ill pat 4 dose im	40 MCG	$114.521	95%	$114.521
J0128	Abarelix injection	10 MG	$68.620
J0130	Abciximab injection	10 MG	$416.273
J0132	Acetylcysteine injection	100 MG	$1.937
J0133	Acyclovir injection	5 MG	$0.023
J0135	Adalimumab injection	20 MG	$308.330
J0150	Injection adenosine 6 MG	6 MG	$30.491
J0152	Adenosine injection	30 MG	$68.934
J0170	Adrenalin epinephrin inject	1 ML	$0.988
J0180	Agalsidase beta injection	1 MG	$127.200
J0205	Alglucerase injection	10 UNITS	$39.220
J0207	Amifostine	500 MG	$463.266
J0210	Methyldopate hcl injection	250 MG	$10.006
J0215	Alefacept	0.5 MG	$26.308
J0256	Alpha 1 proteinase inhibitor	10 MG	$3.306
J0270	Alprostadil for injection	1.25 MCG	$1.802
J0275	Alprostadil urethral suppos	125 MCG	$22.838
J0278	Amikacin sulfate injection	100 MG	$1.212
J0280	Aminophyllin 250 MG inj	250 MG	$0.371
J0282	Amiodarone HCl	30 MG	$0.279
J0285	Amphotericin B	50 MG	$9.445			95%	$10.280
J0287	Amphotericin b lipid complex	10 MG	$11.111			95%	$21.850
J0288	Ampho b cholesteryl sulfate	10 MG	$12.000			95%	$15.200
J0289	Amphotericin b liposome inj	10 MG	$21.245			95%	$35.800
J0290	Ampicillin 500 MG inj	500 MG	$2.372
J0295	Ampicillin sodium per 1.5 gm	1.5 GM	$4.954
J0300	Amobarbital 125 MG inj	125 MG	$2.274
J0330	Succinycholine chloride inj	20 MG	$0.185
J0360	Hydralazine hcl injection	20 MG	$8.675
J0365	Aprotonin, 10,000 kiu	10000 KIU	$2.522
J0456	Azithromycin	500 MG	$12.257
J0460	Atropine sulfate injection	0.3 MG	$0.185
J0470	Dimecaprol injection	100 MG	$25.315
J0475	Baclofen 10 MG injection	10 MG	$198.544			95%	$215.180
J0476	Baclofen intrathecal trial	50 MCG	$69.631			95%	$79.800
J0480	Basiliximab	20 MG	$1,385.861
J0500	Dicyclomine injection	20 MG	$15.334
J0515	Inj benztropine mesylate	1 MG	$17.078
J0530	Penicillin g benzathine inj	600000 UNITS	$13.278
J0540	Penicillin g benzathine inj	1200000 UNITS	$28.453
J0550	Penicillin g benzathine inj	2400000 UNITS	$30.575
J0560	Penicillin g benzathine inj	600000 UNITS	$21.219
J0570	Penicillin g benzathine inj	1200000 UNITS	$36.297
J0580	Penicillin g benzathine inj	2400000 UNITS	$42.098
J0583	Bivalirudin	1 MG	$1.750
J0585	Botulinum toxin a per unit	1 UNIT	$5.035
J0587	Botulinum toxin type B	100 UNITS	$8.164
J0592	Buprenorphine hydrochloride	0.1 MG	$0.720
J0595	Butorphanol tartrate 1 mg	1 MG	$0.718
J0600	Edetate calcium disodium inj	1000 MG	$40.185
J0610	Calcium gluconate injection	10 ML	$0.418
J0630	Calcitonin salmon injection	400 UNITS	$39.941
J0636	Inj calcitriol per 0.1 mcg	0.1 MCG	$0.525
J0637	Caspofungin acetate	5 MG	$32.224							Revised 01/01/07
J0640	Leucovorin calcium injection	50 MG	$0.931
J0670	Inj mepivacaine HCL/10 ml	10 ML	$1.511
J0690	Cefazolin sodium injection	500 MG	$1.191
J0692	Cefepime HCl for injection	500 MG	$7.940
J0694	Cefoxitin sodium injection	1 GM	$6.843
J0696	Ceftriaxone sodium injection	250 MG	$1.617							Revised 01/01/07
J0697	Sterile cefuroxime injection	750 MG	$0.799
J0698	Cefotaxime sodium injection	1 GM	$4.163
J0702	Betamethasone acet&sod phosp	3 MG	$5.192							Revised 01/01/2008
J0704	Betamethasone sod phosp/4 MG	4 MG	$1.133
J0706	Caffeine citrate injection	5 MG	$3.539
J0713	Inj ceftazidime per 500 mg	500 MG	$3.978
J0715	Ceftizoxime sodium / 500 MG	500 MG	$4.444
J0720	Chloramphenicol sodium injec	1 GM	$11.217
J0725	Chorionic gonadotropin/1000u	1000 UNITS	$3.696
J0735	Clonidine hydrochloride	1 MG	$66.038
J0740	Cidofovir injection	375 MG	$763.147
J0743	Cilastatin sodium injection	250 MG	$13.123							Revised 01/01/07
J0744	Ciprofloxacin iv	200 MG	$8.145							Revised 01/01/2008
J0745	Inj codeine phosphate /30 MG	30 MG	$1.049
J0760	Colchicine injection	1 MG	$4.679
J0770	Colistimethate sodium inj	150 MG	$21.508
J0780	Prochlorperazine injection	10 MG	$2.033
J0795	Corticorelin ovine triflutal	1 MCG	$4.174
J0800	Corticotropin injection	40 UNITS	$116.596
J0835	Inj cosyntropin per 0.25 MG	0.25 MG	$62.914
J0850	Cytomegalovirus imm IV /vial	PER VIAL	$853.183
J0878	Daptomycin injection	1 MG	$0.327
J0881	Darbepoetin alfa, non-esrd	1 MCG	$2.975							Revised 01/01/2008
J0882	Darbepoetin alfa, esrd use	1 MCG	$2.975							Revised 01/01/2008
J0885	Epoetin alfa, non-esrd	1000 UNITS	$9.362
J0886	Epoetin alfa, esrd	1000 UNITS	$9.202							Revised 01/01/2008
J0895	Deferoxamine mesylate inj	500 MG	$14.843			95%	$15.630
J0945	Brompheniramine maleate inj	10 MG	$0.798
J0970	Estradiol valerate injection	40 MG	$35.069
J1000	Depo-estradiol cypionate inj	5 MG	$5.565
J1020	Methylprednisolone 20 MG inj	20 MG	$2.327
J1030	Methylprednisolone 40 MG inj	40 MG	$5.079
J1040	Methylprednisolone 80 MG inj	80 MG	$9.267
J1051	Medroxyprogesterone inj	50 MG	$5.484
J1060	Testosterone cypionate 1 ML	1 ML	$4.142
J1070	Testosterone cypionat 100 MG	100 MG	$5.420
J1080	Testosterone cypionat 200 MG	200 MG	$11.635
J1094	Inj dexamethasone acetate	1 MG	$0.230
J1100	Dexamethasone sodium phos	1 MG	$0.143
J1110	Inj dihydroergotamine mesylt	1 MG	$24.373
J1120	Acetazolamid sodium injectio	500 MG	$15.285
J1160	Digoxin injection	0.5 MG	$1.132
J1162	Digoxin immune fab (ovine)	PER VIAL	$533.715
J1165	Phenytoin sodium injection	50 MG	$0.899
J1170	Hydromorphone injection	4 MG	$1.748			95%	$1.490
J1190	Dexrazoxane HCl injection	250 MG	$180.128
J1200	Diphenhydramine hcl injectio	50 MG	$0.732
J1205	Chlorothiazide sodium inj	500 MG	$123.840
J1212	Dimethyl sulfoxide 50% 50 ML	50 ML	$44.244
J1230	Methadone injection	10 MG	$3.245			95%	$0.750
J1240	Dimenhydrinate injection	50 MG	$4.454
J1245	Dipyridamole injection	10 MG	$1.561
J1250	Inj dobutamine HCL/250 mg	250 MG	$5.228			95%	$4.740
J1260	Dolasetron mesylate	10 MG	$6.890
J1265	Dopamine injection	40 MG	$0.689
J1270	Injection, doxercalciferol	1 MCG	$2.875
J1325	Epoprostenol injection	0.5 MG	$14.389			95%	$12.640
J1327	Eptifibatide injection	5 MG	$15.367							Revised 01/01/2008
J1335	Ertapenem injection	500 MG	$23.071							Revised 01/01/07
J1364	Erythro lactobionate /500 MG	500 MG	$5.901
J1380	Estradiol valerate 10 MG inj	10 MG	$12.603
J1390	Estradiol valerate 20 MG inj	20 MG	$17.534
J1410	Inj estrogen conjugate 25 MG	25 MG	$58.046
J1430	Ethanolamine oleate 100 mg	100 MG	$69.596
J1435	Injection estrone per 1 MG	1 MG	$0.239
J1436	Etidronate disodium inj	300 MG	$71.407
J1438	Etanercept injection	25 MG	$159.931							Revised 01/01/2008
J1440	Filgrastim 300 mcg injection	300 MCG	$189.657							Revised 01/01/2008
J1441	Filgrastim 480 mcg injection	480 MCG	$293.933							Revised 01/01/2008
J1450	Fluconazole	200 MG	$11.053
J1451	Fomepizole, 15 mg	15 MG	$12.328
J1455	Foscarnet sodium injection	1000 MG	$10.490			95%	$13.070
J1457	Gallium nitrate injection	1 MG	$1.247
J1460	Gamma globulin 1 CC inj	1 CC	$10.338
J1470	Gamma globulin 2 CC inj	2 CC	$20.677
J1480	Gamma globulin 3 CC inj	3CC	$31.014
J1490	Gamma globulin 4 CC inj