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	$26.279
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	$1.346
J0280	Aminophyllin 250 MG inj	250 MG	$0.414
J0282	Amiodarone HCl	30 MG	$0.193
J0285	Amphotericin B	50 MG	$9.307			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	$1.781
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