Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2016 through June 30, 2016
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 1.018 | |
Allopurinol Sodium | 500 MG | 1876.507 | |
Aminocaproic acid | 250 MG | 0.25 | |
Aztreonam | 500 MG | 11.487 | |
Bumetanide | 0.25 MG | 0.267 | |
Bupivacaine | 1 ML | 0.081 | |
Clevidipine Butyrate | 1 MG | 2.365 | |
Clindamycin Phosphate | 150 MG | 1.006 | |
Diltiazem Hydrochloride | 5 MG | 0.199 | |
Doxycycline Hyclate | 100 MG | 13.265 | |
Esmolol Hydrochloride | 10 MG | 0.876 | |
Esomeprazole Sodium | 20 MG | 12.564 | |
Famotidine | 10 MG | 0.399 | |
Flumazenil | 0.1 MG | 0.791 | |
Folic Acid | 5 MG | 2.471 | |
Glucarpidase | 10 UNITS | 270.724 | |
Glycopyrrolate | 0.2 MG | 6.639 | |
Hexaminolevulinate HCl | 100 mg, per study dose | 954 | |
Integra Meshed Bilayer Wound Matrix | 1 SQ CM | 44.073 | |
Invega Trinza | 1 MG | 7.562 | |
Ixinity | I IU | 1.461 | |
Labetalol Hcl | 5 MG | 0.343 | |
Metoprolol Tartrate | 1 MG | 0.179 | |
Metronidazole inj | 500 MG | 1.154 | |
Nitroglycerin | 5 MG | 1.07 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.308 | |
Rifampin | 600 MG | 136.586 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.432 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.702 | |
Vasopressin | 20 UNITS | 95.035 |
microCurie 100% AWP = $145.180
microCurie 100% WAC = $120.980