Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2023 through March 31, 2023
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 2.009 | |
Allopurinol Sodium | 500 MG | 2890.625 | |
Aminocaproic acid | 250 MG | 0.311 | |
Aztreonam | 500 MG | 14.697 | |
Bumetanide | 0.25 MG | 0.439 | |
Bupivacaine | 1 ML | 0.158 | |
Clindamycin Phosphate | 150 MG | 1.088 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.764 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.357 | |
Doxycycline Hyclate | 100 MG | 17.545 | |
Esmolol Hydrochloride | 10 MG | 0.283 | |
Famotidine | 10 MG | 0.365 | |
Flumazenil | 0.1 MG | 0.913 | |
Folic Acid | 5 MG | 3.186 | |
Furosemide (Phlow Corporation) | 20 MG | 1.579 | Added January 2023 |
Glucarpidase | 10 UNITS | 380.699 | |
Glycopyrrolate injection | 0.2 MG | 1.455 | |
Immune Globulin (Panzyga) | 500 MG | 71.583 | |
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) | 50 UNITS | 7.694 | |
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) | 50 UNITS | 15.745 | |
Labetalol Hcl | 5 MG | 0.189 | |
Metoprolol Tartrate | 1 MG | 0.146 | |
Metronidazole inj | 500 MG | 1.345 | |
Nitroglycerin | 5 MG | 1.349 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.079 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 11.379 | |
Premetrexed (Sandoz) | 10 MG | 13.639 | Added January 2023 |
Rifampin | 600 MG | 99.719 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.814 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.606 | |
Vasopressin | 20 UNITS | 141.221 | |
Vasopressin (American Regent) | 20 UNITS | 104.855 |
microCurie 100% AWP = $176.640; microCurie 100% WAC = $147.200
"lesser of" methodology applied
Added January 2023
Added January 2023
Added January 2023