Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2019 through December 31, 2019
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 0.875 | |
Allopurinol Sodium | 500 MG | 2530.659 | |
Aminocaproic acid | 250 MG | 0.306 | |
Aztreonam | 500 MG | 12.687 | |
Bumetanide | 0.25 MG | 0.313 | |
Bupivacaine | 1 ML | 0.127 | |
Clindamycin Phosphate | 150 MG | 0.869 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.49227811651336 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.313 | |
Doxycycline Hyclate | 100 MG | 19.045 | |
Esmolol Hydrochloride | 10 MG | 0.345 | |
Famotidine | 10 MG | 0.409 | |
Flumazenil | 0.1 MG | 0.754 | |
Folic Acid | 5 MG | 2.698 | |
Glucarpidase | 10 UNITS | 328.863 | |
Glycopyrrolate injection | 0.2 MG | 3.077 | |
Labetalol Hcl | 5 MG | 0.21 | |
Metoprolol Tartrate | 1 MG | 0.197 | |
Metronidazole inj | 500 MG | 1.254 | |
Nitroglycerin | 5 MG | 1.185 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.146 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 9.793 | |
Rifampin | 600 MG | 105.005 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.345 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.588 | |
Vasopressin | 20 UNITS | 165.466 |
AMP-based payment limit
AMP-based payment limit