2nd Quarter Part B Not Otherwise Classified Drug Fee Schedule

2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective April 1, 2005 through June 30, 2005
Revised 03/18/2005
Name of Drug and Exact Dosage Given must be in Block 19 (paper) or Narrative Field (EMC)
NOTE 1: Payment allowance limits subject to the ASP methodology are based on 4Q04 ASP data.
NOTE 2: Providers should contact their local Medicare contractor processing the claim for the most appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.
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.
** Carrier Priced Changes In Bold  
DRUG NAME DOSAGE Current PAR Current NONPAR  
Abraxane (see Paclitaxel Protein-bound Particles for Injectable Suspension)
**Alfentanil HCL (Alfenta) 500 mcg/5 ml 2.290 2.180
Allopurinol Sodium (Aloprim) ICD-9's 274.9 or 790.6 plus the ICD-9 for the neoplasm. Need name of chemotherapy agent causing the elevation of uric acid and a statement as to why patient can not tolerate oral form of the drug. 500 mg/SDV 448.817 426.380
Amikacin Sulfate (Amikin) 50 mg 0.671 0.640
Amino Acid 500 ml 21.110 20.050
Amino Acid 1000 ml 35.190 33.430
Arginine HCL (R-Gene 10) 30 ml 10.000 9.500
Ascorbic Acid (see Vitamin C - Not Covered By Carrier)
**Atenolol (Tenormin) ICD-9's = 401.0 - 429.9 0.5 mg/ml 0.800 0.760
Atropine Sulfate / Edrophonium Chloride 10 mg 1.368 1.300
Azacitidine (Vidaza) Covered for Myelodysplastic Syndrome - ICD-9 238.7. 1 mg 3.958 3.760
Aztreonam (Azactam) 500 mg 9.364 8.900
** Bacitracin (Bacim) 50,000 U 10.170 9.660
Bretylium Tosylate (Bretylol) 5 mg 0.170 0.160
Brevibloc (See Esmolol Hydrochloride)
Bumetanide (Bumex) 0.25 mg 0.253 0.240
Bupivacaine Hcl, 0..25%, 2 ml (Considered Part of Procedure) 2 ml 0.140 0.130
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure) 2 ml 0.260 0.250
** Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed. 0.25% - 1 ml 0.063 0.060
** Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed. 0.50% - 1 ml 0.068 0.060
** Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400-64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed. 0.75% - 1 ml 0.100 0.100
** Calcium Chloride 100 mg/ml 0.140 0.130
Cardizem IV (see Diltiazem Hydrochloride)
** Cefamanadole Nafate (Mandol) 1 gm 8.610 8.180
** Cefoperazone Sodium (Cefobid) 1 gram 16.380 15.560
Cefotetan Disodium (Cefotan) 1 gram 9.490 9.020
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.02 or 787.03 150 mg 0.482 0.460
Clavulanate Potassium / Ticarcillin Disodium .01 - 3 gm 10.775 10.240
Clindamycin Phosphate (Cleocin) 150 mg 0.597 0.570
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Dantrolene Sodium 20 mg 75.770 71.980
Definity (see Perflutren Lipid Microspheres)
Depacon (see Valproate Sodium)
Denileukin Difitox, Ontak (For 300 mcg, use code J9160) 150 mcg 595.430 565.660
Dextrose 2.5% 2.50% 7.680 7.300
Dextrose 5% 5% 7.860 7.470
Dextrose 10% 500 ml 10.000 9.500
Dextrose 50% 50 ml 3.310 3.140
**Dextrose / Nitroglycerin 5%-20 mg/ 100 ml/250 ml 20 mg/100 ml/250 ml 6.320 6.000
**Dextrose 5% / Sodium Chloride 1000 ml 11.220 10.660
Diprivan (see Propofol)
Diltiazem Hydrochloride (Cardizem IV) 5 mg 0.269 0.260
** Doxycycline Hyclate 100 mg 13.450 12.780
Edecrin Sodium (See Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0) 10 mg 0.529 0.500
** Enalaprilat (Vasotec IV) 1.25 mg 3.650 3.470
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office 500,000 IU/ 1ml 29.840 28.350
Esmolol Hcl. (Brevibloc) Covered when administered in the doctor office or ambulance. Covered ICD-9 = 427.89 (Dosage change from 100 mg to 10 mg.) 10 mg 1.839 1.750
Estradiol 1 gram 13.300 12.640
** Estradiol Pellets Per Pellet Invoice Invoice
** Ethiodized Oil (Ethiodol) 1 ml 8.060 7.660
Ethracrynate Sodium (Edecrin Sodium) 50 mg 19.040 18.090
** Etoposide Phosphate (Etopophus) J9999 covered diagnoses = 151.0-151.9, 155.0, 155.2, 160.0-160.9, 162.0-162.9, 170.0-171.9, 173.0-176.9, 182.0-183.9, 186.0-186.9, 188.0-189.9, 190.5, 191.0-191.9, 194.0-195.8, 200.00 to 207.01, 236.1. 100mg 126.190 119.880
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2 10 mg 0.215 0.200
Flumazenil (Mazicon, Romazicon) 0.1 mg 7.580 7.200
Flumazenil (Mazicon, Romazicon) 0.5 mg/ml 42.830 40.690
Folic Acid 5 mg 0.792 0.750
Glycopyrrolate (Robinul) 0.2mg 0.257 0.240
Graftjacket Gel 1 cc 874.516 830.790
Heparin Sodium 100 units 0.013 0.010
Hetastarch Sodium Cl., 6 gm/500 ml 6 gm 23.040 21.890
Histrelin Implant (Vantas) Covered with ICD-9 185 5 mg 530.000 503.500
** Inamrinone Lactate 5 mg 4.050 3.850
** Isopropyl Alchol/Peginterferon Alfa-2A (Pegasys) Covered indication 070.54 when administered in the office 180 mcg/ml 331.740 315.150
Isoproterenol Hydrochloride 0.2 mg 0.858 0.820
Isoptin IV (see Verapamil Hydrochloride)
Ketamine Hydrochloride (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530. 10 mg 0.100 0.100
Labetalol Hcl (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses. 5 mg 0.084 0.080
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable separately when billed with any other procedures 2.5 mg/ml 0.310 0.290
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug. 0.5 mg 62.010 58.910
Lidocaine Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable when billed with any other procedure. 1 ml 0.223 0.210
Macugen (see Pegaptamib Sodium Injection)
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test. 1 mg 0.328 0.310
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered for ICD-9's= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0-567.9, 599.0-599.9, 615.0-615.9. 500 mg 1.723 1.640
Miconazole (Monistat IV) 10 mg Invoice Invoice
Minocycline Hydrochloride 100 mg 36.816 34.980
Morrhuate Sodium 50 mg 1.669 1.590
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm) 1 gm 6.493 6.170
Netilmicin Sulfate (Netromycin), 150 mg Invoice Invoice
Nitroglycerin IV – Allowed in the Office or Ambulance – In emergency situation. 5 mg 0.090 0.090
Norepinephrine Bitartrate (Levophed Bitartrate) Allow in office or ambulance - emergency situation. 1 mg 2.740 2.600
Normal Saline (Sterile Water) 50 ml 1.430 1.360
Ofloxacin (Floxin IV), 20 mg Invoice Invoice
Orthovisc® (see Sodium Hyaluronate)
**Oxychlorosene Sodium (Clorpactin WCS-90) 1GM 1.850 1.760
Paclitaxel Protein-bound Particles for Injectable Suspension (Abraxane) Covered for ICD-9's 174.0 - 175.9 1 mg 8.440 8.020
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form. 40 mg 9.294 8.830
Pegaptamib Sodium Injection (Macugen) Covered for neovascular (wet) age-related macular degeneration. ICD-9 = 362.52 0.3 mg/1 ml 1054.700 1001.970
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys) Covered indication 070.54 when administered in the office 180mcg/ml 331.740 315.150
** Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication 070.54 when administered in the office. 50 mcg 320.610 304.580
** Peginterferon Alfa-2B, 80mcg 80 mcg 336.600 319.770
** Peginterferon Alfa-2B, 120mcg 120 mcg 353.460 335.790
** Peginterferon Alfa-2B, 150mcg 150 mcg 371.120 352.560
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered 0.000 0.000
Pepcid (See Famotidine)
Perflutren Lipid Microspheres (Definity) 2 ml 124.800 118.560
Potassium Acetate 2 meq 0.030 0.030
Prialt (see Ziconotide Intrathecal Infusion)
Procaine Hydrochloride 1% 2.360 2.240
Procaine Hydrochloride 2% 3.400 3.230
Propofol (Diprivan) 10 mg 0.378 0.360
Protonix IV (see Pantoprazole)
**R-Gene 10 (See Arginine Hcl.)
Rifampin 600 mg 49.928 47.430
Robinul (see Glycopyrrolate)
Sarracenia Purpura 50 ml 0.768 0.730
**Secretin (SecreFlo) Used in secretin stimulation testing Invoice Invoice
** SMZ-TMP (Sulfamethoxazole/Trimethoprim) Documentation as to why the patient needs to be on IV infusion instead of oral medication, must be in block 19 or as an attachment for paper claims or in the notepad for EMC claims. 5ml 3.050 2.900
Sincalide (Kinevac) (Use A4641/Carrier Pays Radiopharmaceuticals by Invoice) 5 mcg 29.410 27.940
Sodium Acetate 2 meq 0.041 0.040
** Sodium Bicarbonate, PF (NACH03) 7.5%/50 ml 2.730 2.590
Sodium Bicarbonate, 8.4% (NACH03) 50 ml 0.143 0.140
Sodium Hyaluronate (Orthovisc®), For Intra-Articular Injection (Billed with CPT code 20610 for coverered indications of osteoarthritis of the knee (715.16, 715.26, 715.36, or 715.96). One injection per knee per week. 30 mg 200.128 190.120
Sodium Tetradecyl Sulfate (Sotradecol) Invoice Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal) 50 mg 0.970 0.920
**Somavert (See Pegvisomant for Injection)
**Sterile Saline / Water, 1000 ml 1000 ml 5.640 5.360
** Sufentanil Citrate (Sufenta) Separate payment allowed when billed with 62310, 62311, 62318, 62319, 76005, 95990, or 96530. If billed with any other procedures, it will be considered part of the procedure and separate payment will not be allowed. 50mcg/ml 9.810 9.320
Tagamet (See Cimetidine Hydrochloride)
Tensilon (See Edrophonium Chloride)
Testosterone 37.5 mg 0.110 0.100
** Testosterone Pellets (Testopel) Per Pellet Invoice Invoice
Tetanus Toxoid (use codes 90702, 90703, and 90718) 12.860 12.220
Valproate Sodium (Depacon) IV, Covered ICD9's = 345.00 - 345.91, Allowed when administered IV, in the physician's office. (Dosage change from 500 mg to 100 mg) 100 mg 0.780 0.740
Vantas (see Histrelin Implant)
Vasopressin 20 units 2.100 2.000
Verapamil Hydrochloride (Isoptin IV) 2.5 mg 0.847 0.800
Vidaza (see Azacitidine)
** Vitamin B Complex (Follow B-12 guidelines) Up to 3ml 0.930 0.880
Vitamin C (Ascorbic Acid) (Non-covered by Carrier)
Ziconotide Intrathecal Infusion (Prialt) Covered for intractable pain when billed with 95990. 25mcg/ml 693.500 658.830
HOCM <= 149 MG/ML 1 ml 0.041 0.040
HOCM 200 - 249 MG/ML 1 ml 0.093 0.090
HOCM 250 - 299 MG/ML 1 ml 0.100 0.100
HOCM 300 - 349 MG/ML 1 ml 0.104 0.100
HOCM 350 - 399 MG/ML 1 ml 0.107 0.100
HOCM >= 400 MG/ML 1 ml 0.191 0.180