Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2022 through March 31, 2022
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 1.973 | |
Allopurinol Sodium | 500 MG | 3175.581 | |
Aminocaproic acid | 250 MG | 0.303 | |
Aztreonam | 500 MG | 14.07 | |
Bumetanide | 0.25 MG | 0.289 | |
Bupivacaine | 1 ML | 0.107 | |
Clindamycin Phosphate | 150 MG | 1.054 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 2.274 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.287 | |
Doxycycline Hyclate | 100 MG | 17.547 | |
Esmolol Hydrochloride | 10 MG | 0.292 | |
Famotidine | 10 MG | 0.434 | |
Flumazenil | 0.1 MG | 0.894 | |
Folic Acid | 5 MG | 2.522 | |
Glucarpidase | 10 UNITS | 345.308 | |
Glycopyrrolate injection | 0.2 MG | 2.072 | |
Immune Globulin (Cutaquig) | 100 MG | 13.526 | |
Immune Globulin (Panzyga) | 500 MG | 65.046 | |
Labetalol Hcl | 5 MG | 0.16 | |
Metoprolol Tartrate | 1 MG | 0.14 | |
Metronidazole inj | 500 MG | 1.177 | |
Nitroglycerin | 5 MG | 1.352 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.122 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 10.673 | |
Rifampin | 600 MG | 98.068 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.497 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.603 | |
Vasopressin | 20 UNITS | 219.428 |
microCurie 100% AWP = $174.020; microCurie 100% WAC = $145.020
"lesser of" methodology applied
Added January 2022