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 $50.477             revised 7/1/06
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 $1.231             revised 7/1/06
J0690 Cefazolin sodium injection 500 MG $1.383              
J0692 Cefepime HCl for injection 500 MG $7.554              
J0694 Cefoxitin sodium injection 1 GM $7.143              
J0696 Ceftriaxone sodium injection 250 MG $5.432              
J0697 Sterile cefuroxime injection 750 MG $4.123              
J0698 Cefotaxime sodium injection 1 GM $4.348              
J0702 Betamethasone acet&sod phosp 3 MG $4.983              
J0704 Betamethasone sod phosp/4 MG 4 MG $0.907              
J0706 Caffeine citrate injection 5 MG $3.373             revised 04/01/2006
J0713 Inj ceftazidime per 500 mg 500 MG $3.969              
J0715 Ceftizoxime sodium / 500 MG 500 MG $3.570              
J0720 Chloramphenicol sodium injec 1 GM $10.178              
J0725 Chorionic gonadotropin/1000u 1000 UNITS $3.722              
J0740 Cidofovir injection 375 MG $740.000              
J0743 Cilastatin sodium injection 250 MG $12.633              
J0744 Ciprofloxacin iv 200 MG $8.443              
J0745 Inj codeine phosphate /30 MG 30 MG $0.716              
J0760 Colchicine injection 1 MG $4.446              
J0770 Colistimethate sodium inj 150 MG $24.199              
J0780 Prochlorperazine injection 10 MG $3.251              
J0795 Corticorelin ovine triflutal 1 MCG $4.063             corrected code dosage
J0800 Corticotropin injection 40 UNITS $107.755              
J0835 Inj cosyntropin per 0.25 MG 0.25 MG $65.943              
J0850 Cytomegalovirus imm IV /vial 1 VIAL $721.415             corrected code dosage
J0878 Daptomycin injection 1 MG $0.294              
J0881 Darbepoetin alfa, non-esrd 1 MCG $2.989              
J0882 Darbepoetin alfa, esrd use 1 MCG $2.989              
J0885 Epoetin alfa, non-esrd 1000 UNITS $9.027              
J0886 Epoetin alfa, esrd 1000 UNITS $9.570              
J0895 DeferoxAMIne mesylate inj 500 MG $15.204     95% $15.630      
J0970 Estradiol valerate injection 40 MG $30.979              
J1000 Depo-estradiol cypionate inj 5 MG $5.292              
J1020 Methylprednisolone 20 MG inj 20 MG $2.807              
J1030 Methylprednisolone 40 MG inj 40 MG $5.270              
J1040 Methylprednisolone 80 MG inj 80 MG $9.283              
J1051 Medroxyprogesterone inj 50 MG $5.153              
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 $12.310              
J1100 Dexamethasone sodium phos 1 MG $0.121              
J1110 Inj dihydroergotAMIne mesylt 1 MG $25.341              
J1120 AcetazolAMId sodium injectio 500 MG $14.905              
J1160 Digoxin injection 0.5 MG $3.974              
J1162 Digoxin immune fab (ovine) PER VIAL $540.910              
J1165 Phenytoin sodium injection 50 MG $0.663              
J1170 Hydromorphone injection 4 MG $1.605     95% $1.490      
J1180 Dyphylline inj 500 MG $8.045              
J1190 Dexrazoxane HCl injection 250 MG $186.715              
J1200 DiphenhydrAMIne hcl injectio 50 MG $0.760              
J1205 Chlorothiazide sodium inj 500 MG $10.197              
J1212 Dimethyl sulfoxide 50% 50 ML 50 ML $42.368              
J1230 Methadone injection 10 MG $3.245     95% $0.750      
J1240 Dimenhydrinate injection 50 MG $3.830              
J1245 Dipyridamole injection 10 MG $1.680              
J1250 Inj dobutAMIne HCL/250 mg 250 MG $5.024     95% $4.740      
J1260 Dolasetron mesylate 10 MG $6.368