Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2020 through June 30, 2020
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 1.507 | |
Allopurinol Sodium | 500 MG | 2769.89 | |
Aminocaproic acid | 250 MG | 0.291 | |
Aztreonam | 500 MG | 12.807 | |
Bumetanide | 0.25 MG | 0.297 | |
Bupivacaine | 1 ML | 0.094 | |
Clindamycin Phosphate | 150 MG | 0.904 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.62 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.371 | |
Doxycycline Hyclate | 100 MG | 18.782 | |
Esmolol Hydrochloride | 10 MG | 0.319 | |
Famotidine | 10 MG | 0.403 | |
Flumazenil | 0.1 MG | 0.647 | |
Folic Acid | 5 MG | 2.771 | |
Givosiran (Givlaari) | 0.5 MG | 106.269841269841 | Added April 2020 |
Glucarpidase | 10 UNITS | 328.863 | |
Glycopyrrolate injection | 0.2 MG | 2.778 | |
Immune Globulin (Asceniv) | 500 MG | 468.135 | Added April 2020 |
Immune Globulin (Cutaquig) | 100 MG | 17.445 | |
Immune Globulin (Panzyga) | 500 MG | 70.049 | |
Immune Globulin (Xemblify) | 100 MG | 17.613 | Added April 2020 |
Labetalol Hcl | 5 MG | 0.394 | |
Metoprolol Tartrate | 1 MG | 0.168 | |
Metronidazole inj | 500 MG | 1.229 | |
Nitroglycerin | 5 MG | 1.216 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.323 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 9.753 | |
Pegfilgrastim-bmez (Ziextenzo)? | 0.5 MG | 336.941325 | |
Rabies Immune Globulin (Kedrab) | 150 IU | 291.95 | |
Rifampin | 600 MG | 110.463 | |
Rituximab-pvvr (Ruxience) | 10 MG | 73.8304 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.265 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.586 | |
Vasopressin | 20 UNITS | 179.848 |
Added April 2020