Medicare Part B payment allowance limits for drugs not otherwise classified - Effective July 1, 2020 through September 30, 2020
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 1.676 | |
Allopurinol Sodium | 500 MG | 2812.246 | |
Aminocaproic acid | 250 MG | 0.356 | |
Aztreonam | 500 MG | 12.76 | |
Bumetanide | 0.25 MG | 0.333 | |
Bupivacaine | 1 ML | 0.075 | |
Clindamycin Phosphate | 150 MG | 0.787 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.564 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.333 | |
Doxycycline Hyclate | 100 MG | 18.678 | |
Esmolol Hydrochloride | 10 MG | 0.384 | |
Famotidine | 10 MG | 0.42 | |
Flumazenil | 0.1 MG | 0.656 | |
Folic Acid | 5 MG | 2.63 | |
Glucarpidase | 10 UNITS | 328.863 | |
Glycopyrrolate injection | 0.2 MG | 2.619 | |
Immune Globulin (Asceniv) | 500 MG | 481.77 | |
Immune Globulin (Cutaquig) | 100 MG | 19.486 | |
Immune Globulin (Panzyga) | 500 MG | 67.999 | |
Labetalol Hcl | 5 MG | 0.253 | |
Metoprolol Tartrate | 1 MG | 0.179 | |
Metronidazole inj | 500 MG | 1.263 | |
Nitroglycerin | 5 MG | 1.233 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.244 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 10.108 | |
Rabies Immune Globulin (Kedrab) | 150 IU | 271.401 | |
Rifampin | 600 MG | 106.233 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.315 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.595 | |
Vasopressin | 20 UNITS | 191.824 |