Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2019 through June 30, 2019
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 1.485 | |
Allopurinol Sodium | 500 MG | 2920.343 | |
Aminocaproic acid | 250 MG | 0.307 | |
Aripiprazole lauroxil (Aristada Initio) | 1 MG | 2.71 | |
Aztreonam | 500 MG | 13.074 | |
Bendamustine Hcl (Eagle) | 1 MG | 23.663 | Added April 2019 |
Bumetanide | 0.25 MG | 0.293 | |
Bupivacaine | 1 ML | 0.095 | |
Clindamycin Phosphate | 150 MG | 0.908 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.406 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.278 | |
Doxycycline Hyclate | 100 MG | 18.405 | |
Esmolol Hydrochloride | 10 MG | 0.717 | |
Famotidine | 10 MG | 0.388 | |
Flumazenil | 0.1 MG | 0.973 | |
Folic Acid | 5 MG | 2.296 | |
Glucarpidase | 10 UNITS | 313.198 | |
Glycopyrrolate injection | 0.2 MG | 3.853 | |
Labetalol Hcl | 5 MG | 0.177 | |
Metoprolol Tartrate | 1 MG | 0.188 | |
Metronidazole inj | 500 MG | 1.172 | |
Nitroglycerin | 5 MG | 1.138 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.114 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 9.185 | |
Rifampin | 600 MG | 91.923 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.396 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.571 | |
Vasopressin | 20 UNITS | 165.121 |