Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2016 through March 31, 2016
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 0.913 | |
Allopurinol Sodium | 500 MG | 1106.947 | |
Aminocaproic acid | 250 MG | 0.253 | |
Aztreonam | 500 MG | 15.571 | |
Bumetanide | 0.25 MG | 0.284 | |
Bupivacaine | 1 ML | 0.083 | |
Clavulanate Potassium/Ticarcillin Disodium | 0.1-3 GM | 14.09482 | |
Clevidipine Butyrate | 1 MG | 2.82 | |
Clindamycin Phosphate | 150 MG | 1.057 | |
Diltiazem Hydrochloride | 5 MG | 0.204 | |
Doxycycline Hyclate | 100 MG | 14.004 | |
Esmolol Hydrochloride | 10 MG | 0.838 | |
Esomeprazole Sodium | 20 MG | 12.991 | |
Famotidine | 10 MG | 0.405 | |
Flumazenil | 0.1 MG | 0.635 | |
Folic Acid | 5 MG | 2.583 | |
Glucarpidase | 10 UNITS | 270.555 | |
Glycopyrrolate | 0.2 MG | 6.627 | |
Hexaminolevulinate HCl | 100 mg, per study dose | 883.828 | |
Integra Meshed Bilayer Wound Matrix | 1 SQ CM | 40.25 | |
Invega Trinza | 1 MG | 7.595 | Added January 2016 |
Ixinity | I IU | 1.46733649183147 | Added January 2016 |
Labetalol Hcl | 5 MG | 0.19 | |
Metoprolol Tartrate | 1 MG | 0.155 | |
Metronidazole inj | 500 MG | 1.148 | |
Nitroglycerin | 5 MG | 0.767 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.305 | |
Rifampin | 600 MG | 141.319 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.332 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.506 | |
SurgiMend | 0.5 SQ CM | 12.426 | |
Vasopressin | 20 UNITS | 94.666 |
microCurie 100% AWP = $145.18
microCurie 100% WAC = $120.98
Added January 2016