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 $117.357              
90375 Rabies ig, im/sc 150 IU $65.132              
90376 Rabies ig, heat treated 150 IU $67.891             corrected 6/22/06
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% $113.914          
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% $113.914          
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 $4.611              
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 $8.287              
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 $3.026              
J0882 Darbepoetin alfa, esrd use 1 MCG $3.026              
J0885 Epoetin alfa, non-esrd 1000 UNITS $9.403              
J0886 Epoetin alfa, esrd 1000 UNITS $9.479              
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