Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2021 - June 30, 2021
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 2.261 | |
Allopurinol Sodium | 500 MG | 3203.906 | |
Aminocaproic acid | 250 MG | 0.335 | |
Aztreonam | 500 MG | 13.685 | |
Bumetanide | 0.25 MG | 0.304 | |
Bupivacaine | 1 ML | 0.087 | |
Clindamycin Phosphate | 150 MG | 0.758 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 2.21 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.339 | |
Doxycycline Hyclate | 100 MG | 19.508 | |
Esmolol Hydrochloride | 10 MG | 0.271 | |
Famotidine | 10 MG | 0.433 | |
Flumazenil | 0.1 MG | 0.786 | |
Folic Acid | 5 MG | 2.901 | |
Glucarpidase | 10 UNITS | 345.176 | |
Glycopyrrolate injection | 0.2 MG | 2.242 | |
Immune Globulin (Cutaquig) | 100 MG | 16.437 | |
Immune Globulin (Panzyga) | 500 MG | 62.292 | |
Labetalol Hcl | 5 MG | 0.153 | |
Metoprolol Tartrate | 1 MG | 0.145 | |
Metronidazole inj | 500 MG | 1.194 | |
Nitroglycerin | 5 MG | 1.282 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.248 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 10.19 | |
Rabies Immune Globulin (Kedrab) | 150 IU | 258.074 | |
Rifampin | 600 MG | 106.173 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.513 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.582 | |
Vasopressin | 20 UNITS | 204.544 |
microCurie 100% AWP = $169.090; microCurie 100% WAC = $140.910