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
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
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
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
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
J0690	Cefazolin sodium injection	500 MG	$1.287
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
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	$3.032							Revised 01/01/2008
J0882	Darbepoetin alfa, esrd use	1 MCG	$3.032							Revised 01/01/2008
J0885	Epoetin alfa, non-esrd	1000 UNITS	$9.339
J0886	Epoetin alfa, esrd	1000 UNITS	$9.245							Revised 01/01/2008
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	$155.390							Revised 01/01/2008
J1440	Filgrastim 300 mcg injection	300 MCG	$184.978							Revised 01/01/2008
J1441	Filgrastim 480 mcg injection	480 MCG	$290.316							Revised 01/01/2008