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Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs,,,
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"Effective July 1, 2013 through September 30, 2013",,,
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Note 1: Payment allowance limits subject to the ASP methodology are based on 1Q13 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 3: 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.,,,
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Drug Generic Name (Trade Name),Dosage,Payment Limit,Notes
Alfentanil Hcl,500 MCG,$1.977,
Allopurinol Sodium,500 MG,$320.671,
Aminocaproic acid,250 MG,$0.073,
Aztreonam,500 MG,$12.863,
Bumetanide,0.25 MG,$0.208,
Bupivacaine,1 ML,$0.096,
Carfilzomib,1 MG,$29.291,
Clavulanate Potassium/Ticarcillin Disodium,0.1-3 GM,$11.800,
Clevidipine Butyrate,1 MG,$2.834,
Clindamycin Phosphate,150 MG,$1.871,
Diltiazem Hydrochloride,5 MG,$0.203,
Doxycycline Hyclate,100 MG,$15.027,
Esmolol Hydrochloride,10 MG,$0.788,
Esomeprazole Sodium,20 MG,$18.372,
Etomidate,2 MG,$0.723,
Famotidine,10 MG,$0.370,
Flumazenil,0.1 MG,$0.915,
Folic Acid,5 MG,$2.171,
Fospropofol disodium injection,35 MG,$1.272,
Glucarpidase,10 UNITS,$233.730,
Glycopyrrolate,0.2 MG,$0.576,
Hexaminolevulinate HCl,"100 mg, per study dose",$741.576,
Integra Meshed Bilayer Wound Matrix,1 SQ CM,$29.169,
Labetalol Hcl,5 MG,$0.118,
Metoprolol Tartrate,1 MG,$0.309,
Metronidazole inj,500 MG,$0.900,
Nitroglycerin,5 MG,$0.416,
Olanzapine short acting intramuscular injection,0.5 MG,$1.332,
Pertuzumab,10 MG,$102.092,
Propofol,10 MG,$0.117,
Rifampin,600 MG,$70.088,
"Sodium Chloride, Hypertonic (3% - 5% infusion)",250 CC,$0.700,
Sulfamethoxazole-Trimethoprim,400-80 MG,$0.312,
SurgiMend,0.5 SQ CM,$11.961,
Taliglucerase Alfa,10 UNITS,$30.904,
Vasopressin,20 UNITS,$3.821,
Vecuronium bromide,1 MG,$0.354,
Ziv-Aflibercept,1 MG,$11.098,