Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2021 through December 31, 2021
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 2.118 | |
Allopurinol Sodium | 500 MG | 3212.092 | |
Aminocaproic acid | 250 MG | 0.303 | |
Aztreonam | 500 MG | 14.266 | |
Bumetanide | 0.25 MG | 0.307 | |
Bupivacaine | 1 ML | 0.09 | |
Clindamycin Phosphate | 150 MG | 0.918 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 2.273 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.278 | |
Doxycycline Hyclate | 100 MG | 18.396 | |
Esmolol Hydrochloride | 10 MG | 0.324 | |
Famotidine | 10 MG | 0.412 | |
Flumazenil | 0.1 MG | 0.738 | |
Folic Acid | 5 MG | 3.08 | |
Glucarpidase | 10 UNITS | 345.308 | |
Glycopyrrolate injection | 0.2 MG | 2.26 | |
Immune Globulin (Cutaquig) | 100 MG | 13.324 | |
Immune Globulin (Panzyga) | 500 MG | 63.582 | |
Labetalol Hcl | 5 MG | 0.252 | |
Metoprolol Tartrate | 1 MG | 0.15 | |
Metronidazole inj | 500 MG | 1.235 | |
Nitroglycerin | 5 MG | 1.367 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.323 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 10.693 | |
Rifampin | 600 MG | 103.478 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.501 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.619 | |
Vasopressin | 20 UNITS | 219.196 |
microCurie 100% AWP = $170.780; microCurie 100% WAC = $142.320
"lesser of" methodology applied