| HCPCS Code | Code Dosage | Payment Limit |
Vaccine AWP % | Vaccine Limit | Infusion AWP % | DME infusion limit | Blood AWP % | Blood limit | Clotting factor | Note |
|---|---|---|---|---|---|---|---|---|---|---|
Q9965 - Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml |
1 ML | 0.852 | - | - | - | - | - | - | ||
Q9966 - Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml |
1 ML | 0.326 | - | - | - | - | - | - | ||
Q9967 - Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml |
1 ML | 0.114 | - | - | - | - | - | - | ||
Q9991 - Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg |
Less than or equal to 100 MG | 1737.257 | - | - | - | - | - | - | ||
Q9992 - Injection, buprenorphine extended-release (sublocade), greater than 100 mg |
Greater than 100 MG | 1737.257 | - | - | - | - | - | - | ||
| * Effective January 1, 2021 through March 31, 2021 | ||||||||||
Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2021 through March 31, 2021
| Drug name | Dosage | Payment limit | Notes |
|---|---|---|---|
| Alfentanil Hcl | 500 MCG | 1.917 | |
| Allopurinol Sodium | 500 MG | 3149.724 | |
| Aminocaproic acid | 250 MG | 0.341 | |
| Aztreonam | 500 MG | 12.574 | |
| Bumetanide | 0.25 MG | 0.354 | |
| Bupivacaine | 1 ML | 0.064 | |
| Clindamycin Phosphate | 150 MG | 0.89 | |
| Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.737 | includes clotting factor furnishing fee |
| Diltiazem Hydrochloride | 5 MG | 0.331 | |
| Doxycycline Hyclate | 100 MG | 18.736 | |
| Esmolol Hydrochloride | 10 MG | 0.33 | |
| Famotidine | 10 MG | 0.389 | |
| Flumazenil | 0.1 MG | 0.683 | |
| Folic Acid | 5 MG | 2.638 | |
| Glucarpidase | 10 UNITS | 328.863 | |
| Glycopyrrolate injection | 0.2 MG | 2.399 | |
| Immune Globulin (Asceniv) | 500 MG | 481.77 | |
| Immune Globulin (Cutaquig) | 100 MG | 18.184 | |
| Immune Globulin (Panzyga) | 500 MG | 64.513 | |
| Labetalol Hcl | 5 MG | 0.151 | |
| Metoprolol Tartrate | 1 MG | 0.123 | |
| Metronidazole inj | 500 MG | 1.221 | |
| Nitroglycerin | 5 MG | 1.255 | |
| Olanzapine short acting intramuscular injection | 0.5 MG | 1.263 | |
| Paliperidone Palmitate (Invega Trinza) | 1 MG | 10.195 | |
| Rabies Immune Globulin (Kedrab) | 150 IU | 231.649 | |
| Rifampin | 600 MG | 104.387 | |
| Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.464 | |
| Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.627 | |
| Vasopressin | 20 UNITS | 203.34 |