Payment Allowance Limits for Medicare Part B Drugs
Effective July 1, 2006 through September 30, 2006
Note 1: Payment allowance limits subject to the ASP methodology are based on 1Q06 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	$118.289							Revised 1/1/2007
90375	Rabies ig, im/sc	150 IU	$65.132
90376	Rabies ig, heat treated	150 IU	$67.891
90385	Rh ig, minidose, im	50 MCG	$11.174
90585	Bcg vaccine, percut	50 MG	$115.847
90586	Bcg vaccine, intravesical	1 EACH	$112.686
90632	Hep a vaccine, adult im	1 ML	$41.643
90633	Hep a vacc, ped/adol, 2 dose	1 ML	$23.906
90634	Hep a vacc, ped/adol, 3 dose	3 EACH	$23.906
90645	Hib vaccine, hboc, im	1 EACH	$21.492
90647	Hib vaccine, prp-omp, im	0.5 ML	$21.492
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	$157.820
90691	Typhoid vaccine, im	0.5 ML	$52.343
90700	Dtap vaccine, < 7 yrs, im	0.5 ML	$30.457
90702	Dt vaccine < 7, im	0.5 ML	$18.300
90703	Tetanus vaccine, im	0.5 ML	$19.260
90704	Mumps vaccine, sc	0.5 ML	$19.169
90705	Measles vaccine, sc	0.5 ML	$14.593
90706	Rubella vaccine, sc	0.5 ML	$16.243
90707	Mmr vaccine, sc	0.5 ML	$38.514
90713	Poliovirus, ipv, sc/im	0.5 ML	$26.228
90714	Td vaccine no prsrv >/= 7 im	0.5 ML	$18.481
90716	Chicken pox vaccine, sc	0.5 ML	$67.739
90717	Yellow fever vaccine, sc	0.5 ML	$54.440
90718	Td vaccine > 7, im	0.5 ML	$18.468
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	$113.914	95%	#######
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	$58.435	95%	$58.435
90747	Hepb vacc, ill pat 4 dose im	40 MCG	$113.914	95%	#######
J0128	Abarelix injection	10 MG	$68.620
J0130	Abciximab injection	10 MG	$443.737
J0132	Acetylcysteine injection	100 MG	$1.894
J0133	Acyclovir injection	5 MG	$0.028
J0135	Adalimumab injection	20 MG	$303.359
J0150	Injection adenosine 6 MG	6 MG	$30.766
J0152	Adenosine injection	30 MG	$70.051
J0170	Adrenalin epinephrin inject	1 ML	$0.602
J0180	Agalsidase beta injection	1 MG	$127.200
J0205	Alglucerase injection	10 UNITS	$39.220
J0207	Amifostine	500 MG	$451.224
J0210	Methyldopate hcl injection	250 MG	$9.970
J0215	Alefacept	0.5 MG	$25.938
J0256	Alpha 1 proteinase inhibitor	10 MG	$3.253
J0270	Alprostadil for injection	1.25 MCG	$1.854
J0275	Alprostadil urethral suppos	125 MCG	$21.681
J0278	Amikacin sulfate injection	100 MG	$1.142
J0280	Aminophyllin 250 MG inj	250 MG	$0.401
J0282	Amiodarone HCl	30 MG	$0.245
J0285	Amphotericin B	50 MG	$8.330			95%	$10.280
J0287	Amphotericin b lipid complex	10 MG	$11.036			95%	$21.850
J0288	Ampho b cholesteryl sulfate	10 MG	$12.000			95%	$15.200
J0289	Amphotericin b liposome inj	10 MG	$15.417			95%	$35.800
J0290	Ampicillin 500 MG inj	500 MG	$2.308
J0295	Ampicillin sodium per 1.5 gm	1.5 GM	$5.572							Revised 1/1/2007
J0300	Amobarbital 125 MG inj	125 MG	$2.415
J0330	Succinycholine chloride inj	20 MG	$0.192
J0350	Injection anistreplase 30 u	30 UNITS	$2,268.460
J0360	Hydralazine hcl injection	20 MG	$6.361
J0365	Aprotonin, 10,000 kiu	10000 KIU	$2.499
J0456	Azithromycin	500 MG	$20.232
J0460	Atropine sulfate injection	0.3 MG	$0.284
J0470	Dimecaprol injection	100 MG	$21.999
J0475	Baclofen 10 MG injection	10 MG	$198.984			95%	$215.180
J0476	Baclofen intrathecal trial	50 MCG	$71.391			95%	$79.800
J0480	Basiliximab	20 MG	$1,414.533
J0500	Dicyclomine injection	20 MG	$15.531
J0515	Inj benztropine mesylate	1 MG	$14.003
J0530	Penicillin g benzathine inj	600000 UNITS	$13.227
J0540	Penicillin g benzathine inj	1200000 UNITS	$27.833
J0550	Penicillin g benzathine inj	2400000 UNITS	$29.730
J0560	Penicillin g benzathine inj	600000 UNITS	$20.511
J0570	Penicillin g benzathine inj	1200000 UNITS	$35.927
J0580	Penicillin g benzathine inj	2400000 UNITS	$42.104
J0583	Bivalirudin	1 MG	$1.589
J0585	Botulinum toxin a per unit	1 UNIT	$5.029
J0587	Botulinum toxin type B	100 UNITS	$8.077
J0592	Buprenorphine hydrochloride	0.1 MG	$0.737
J0595	Butorphanol tartrate 1 mg	1 MG	$0.757
J0600	Edetate calcium disodium inj	1000 MG	$40.123
J0610	Calcium gluconate injection	10 ML	$0.390
J0630	Calcitonin salmon injection	400 UNITS	$40.598
J0636	Inj calcitriol per 0.1 mcg	0.1 MCG	$0.507
J0637	Caspofungin acetate	5 MG	$32.443
J0640	Leucovorin calcium injection	50 MG	$1.023
J0670	Inj mepivacaine HCL/10 ml	10 ML	$1.463
J0690	Cefazolin sodium injection	500 MG	$1.339
J0692	Cefepime HCl for injection	500 MG	$8.131
J0694	Cefoxitin sodium injection	1 GM	$6.911
J0696	Ceftriaxone sodium injection	250 MG	$2.033
J0697	Sterile cefuroxime injection	750 MG	$1.463
J0698	Cefotaxime sodium injection	1 GM	$4.346
J0702	Betamethasone acet&sod phosp	3 MG	$5.147
J0704	Betamethasone sod phosp/4 MG	4 MG	$1.133
J0706	Caffeine citrate injection	5 MG	$3.480
J0713	Inj ceftazidime per 500 mg	500 MG	$3.989
J0715	Ceftizoxime sodium / 500 MG	500 MG	$3.352
J0720	Chloramphenicol sodium injec	1 GM	$10.137
J0725	Chorionic gonadotropin/1000u	1000 UNITS	$3.489
J0735	Clonidine hydrochloride	1 MG	$65.336
J0740	Cidofovir injection	375 MG	$748.519
J0743	Cilastatin sodium injection	250 MG	$13.209
J0744	Ciprofloxacin iv	200 MG	$8.201							Revised 01/01/2008
J0745	Inj codeine phosphate /30 MG	30 MG	$1.148
J0760	Colchicine injection	1 MG	$4.479
J0770	Colistimethate sodium inj	150 MG	$25.517
J0780	Prochlorperazine injection	10 MG	$2.353
J0795	Corticorelin ovine triflutal	1 MCG	$4.097
J0800	Corticotropin injection	40 UNITS	$114.805
J0835	Inj cosyntropin per 0.25 MG	0.25 MG	$62.328
J0850	Cytomegalovirus imm IV /vial	PER VIAL	$776.132
J0878	Daptomycin injection	1 MG	$0.313
J0881	Darbepoetin alfa, non-esrd	1 MCG	$3.003							Revised 01/01/2008
J0882	Darbepoetin alfa, esrd use	1 MCG	$3.003							Revised 01/01/2008
J0885	Epoetin alfa, non-esrd	1000 UNITS	$9.403
J0886	Epoetin alfa, esrd	1000 UNITS	$9.392							Revised 01/01/2008
J0895	Deferoxamine mesylate inj	500 MG	$15.524			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	$33.866
J1000	Depo-estradiol cypionate inj	5 MG	$5.491
J1020	Methylprednisolone 20 MG inj	20 MG	$2.928
J1030	Methylprednisolone 40 MG inj	40 MG	$5.220
J1040	Methylprednisolone 80 MG inj	80 MG	$9.490
J1051	Medroxyprogesterone inj	50 MG	$5.467
J1056	MA/EC contraceptiveinjection	5 MG	$22.885
J1060	Testosterone cypionate 1 ML	1 ML	$4.142
J1070	Testosterone cypionat 100 MG	100 MG	$5.409
J1080	Testosterone cypionat 200 MG	200 MG	$12.707
J1094	Inj dexamethasone acetate	1 MG	$0.230
J1100	Dexamethasone sodium phos	1 MG	$0.135
J1110	Inj dihydroergotamine mesylt	1 MG	$27.642
J1120	Acetazolamid sodium injectio	500 MG	$15.063
J1160	Digoxin injection	0.5 MG	$1.022
J1162	Digoxin immune fab (ovine)	PER VIAL	$521.841
J1165	Phenytoin sodium injection	50 MG	$0.910
J1170	Hydromorphone injection	4 MG	$1.752			95%	$1.490
J1180	Dyphylline injection	500 MG	$8.045
J1190	Dexrazoxane HCl injection	250 MG	$183.289
J1200	Diphenhydramine hcl injectio	50 MG	$0.738
J1205	Chlorothiazide sodium inj	500 MG	$76.756
J1212	Dimethyl sulfoxide 50% 50 ML	50 ML	$42.803
J1230	Methadone injection	10 MG	$3.281			95%	$0.750
J1240	Dimenhydrinate injection	50 MG	$3.652
J1245	Dipyridamole injection	10 MG	$1.619
J1250	Inj dobutamine HCL/250 mg	250 MG	$4.865			95%	$4.740
J1260	Dolasetron mesylate	10 MG	$6.612
J1265	Dopamine injection	40 MG	$0.805
J1270	Injection, doxercalciferol	1 MCG	$3.159
J1320	Amitriptyline injection	20 MG	$2.237
J1325	Epoprostenol injection	0.5 MG	$13.708			95%	$12.640
J1327	Eptifibatide injection	5 MG	$14.560
J1335	Ertapenem injection	500 MG	$23.135
J1364	Erythro lactobionate /500 MG	500 MG	$5.796
J1380	Estradiol valerate 10 MG inj	10 MG	$12.637
J1390	Estradiol valerate 20 MG inj	20 MG	$16.933
J1410	Inj estrogen conjugate 25 MG	25 MG	$58.183
J1430	Ethanolamine oleate 100 mg	100 MG	$69.596
J1435	Injection estrone per 1 MG	1 MG	$0.138
J1436	Etidronate disodium inj	300 MG	$71.407
J1438	Etanercept injection	25 MG	$155.143							Revised 10/1/2006 and 01/01/2008
J1440	Filgrastim 300 mcg injection	300 MCG	$185.277							Revised 01/01/2008
J1441	Filgrastim 480 mcg injection	480 MCG	$289.028							Revised 01/01/2008
J1450	Fluconazole	200 MG	$13.382
J1451	Fomepizole, 15 mg	15 MG	$12.275
J1452	Intraocular Fomivirsen na	1.65 MG	$212.000
J1455	Foscarnet sodium injection	1000 MG	$10.710			95%	$13.070
J1457	Gallium nitrate injection	1 MG	$1.247
J1460	Gamma globulin 1 CC inj	1 CC	$10.867
J1470	Gamma globulin 2 CC inj	2 CC	$21.734
J1480	Gamma globulin 3 CC inj	3CC	$32.596
J1490	Gamma globulin 4 CC inj	4 CC	$43.468
J1500	Gamma globulin 5 CC inj	5 CC	$54.334