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Effective April 1, 2014 through June 30, 2014. Visit the Centers for Medicare & Medicaid Services for more information.


HCPCS Codes & Medicare Payment
Payment Allowance Limits for Medicare Part B Drugs
Effective April 01, 2014  - June 30, 2014
 
For a more complete listing of payment allowance limits for 2014 Click Here

For comprehensive reimbursement assistance at no charge to you, call BDI Access at          
855-234-2273  (855-BDI-CARE).

Please Note:

Payment allowance limits subject to the ASP methodology are based on 4Q13 ASP data.

The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor processing the claim.
 
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HCPCS Code Description HCPCS Code Dosage Payment Limit

90371 Hep b ig, im 1mL $111.453
90375 Rabies ig, im/sc 150 iu $220.149
90376 Rabies ig, heat treated 150 iu $213.035
90385 Rh ig, minidose, im 50 mcg $25.058
90585 Bcg vaccine, percut 50 mg $122.363
90586 Bcg vaccine, intravesical 1 each $122.363
90632 Hep a vaccine, adult im 1 mL $51.055
90654 Flu Vaccine, intradermal, no preserv 0.1mL $18.918
90655 Flu vaccine no preserv 6-35m, im 0.25 mL $17.243
90656 Flu vaccine no preserv 3 yo & >, im 0.5 mL $12.398
90657 Flu vaccine, 6-35 mo, im 0.25 mL $6.022
90662 Flu vaccine prsv free inc antig 0.5mL $31.823
90670 Pneumoccocal vacc, 13 val im 0.5mL $153.963
90672 Flu Vaccine 4 valent nasal 0.2mL $24.596
90675 Rabies vaccine, im 1 mL $231.767
90685 'Flu vac no prsv 4 val 6-35 m 0.25mL $23.228
90686 Flu vac no prsv 4 val 3 yrs+ 0.5mL $19.409
90691 Typhoid vaccine, im 0.m mL $70.564
90703 Tetanus vaccine, im 0.5 mL $39.026
90714 Td  vaccine no prsrv >/= 7 yo, im 0.5 mL $21.154
90715 Tdap => 7 yo, im 0.5 mL $33.603
90732 Pneumococcal vaccine 0.5 mL $77.847
90733 Meningococcal vaccine, sc 0.5 mL $106.492
90740 Hepb vacc, ill pat 3 dose im 40 mcg $119.415
90743 Hep b vacc, adol, 2 dose, im 1 dose $24.216
90744 Hepb vacc ped/adol 3 dose im 1 dose $24.216
90746 Hep b vaccine, adult, im 20 mcg $59.708
90747 Hepb vacc, ill pat 4 dose im 40 mcg $119.415
J0135 Adalimumab injection 20 mg $567.683
J0171 Adrenalin epinephrin injection 0.1 mg $0.154
J0178 Afilbercept injection (opthalmic) 1mg $980.500
J0278 Amikacin sulfate injection 100 mg $1.280
J0280 Aminophyllin 250 mg inj 250 mg $1.552
J0290 Ampicillin 500 mg inj 500  mg $1.558
J0295 Ampicillin sodium per 1.5 gm 1.5 gm $1.764
J0348 Anidulafungin injection 1 mg $0.728
J0360 Hydralazine hcl injection 30 mg $3.185
J0456 Azithromycin 500 mcg $3.434
J0461 Atropine sulfate injection 0.3 mg $0.046
J0585 injection, onabotulinumtoxinA 1 unit $5.425
J0586 AbobotulinumtoxinA 5 unit $7.338
J0587 Inj, rimabotulinumtoxinB 100 units $11.138
J0588 Incobotulinumtoxin A 1 unit $4.483
J0597 C-1 esterase, berinert 10 units $36.350
J0598 C1 esterase inhibitor inj 10 IU $49.214
J0637 Casofungin acetate 5 mg $13.090
J0368 Canakinumab injection 1 mg $91.031
J0640 Leucovorin calcium injection 50 mg $3.958
J0641 Levoleucovorin injection 0.5 mg $1.701
J0690 Cefazolin sodium injection 500 mg $0.787
J0692 Cefepime HCI for injection 500 mg $2.577
J0694 Cefoxitin sodium injection 1 gm $5.059
J0696 Ceftriaxone sodium injection 250 mg $0.706
J0697 Sterile cefurxime injection 750 mg $3.111
J0698 Cefotaxime sodium injection 1 gm $1.950
J0702 Betamethasone acet & sod phosp 3 mg $5.736
J0706 Caffeine citrate injection 5 mg $0.554
J0712 Ceftaroline Fosamil inj 10mg $1.024
J0713 Inj ceftazidime per 500 mg 500 mg $2.151
J0743 Cilastatin sodium injection 250 mg $5.933
J0744 Ciprofloxacin iv 200 mg $1.096
J0770 Colistimethate sodium inj 150 mg $11.750
J0775 Collagenase clost hist inj 0.01mg $38.432
J0834 Cosyntropin cortrosyn inj 0.25 mg $62.937
J0840 Crotalide poly immune fab UP to 1 gm $2420.000
J0850 Cytomegalovirus imm IV/vial per vial $1013.869
J0878 Daptomycin injection 1 mg $0.636
J0894 Decitabine injection 1 mg $29.859
J0895 Deferoxamine mesylate inj 500 mg $8.250
J0897 Denosumab injection 1mg $14.323
J1000 Depo-estradiol cypionate inj 5 mg $8.834
J1020 Methylprednisolone 20 mg inj 20 mg $3.178
J1030 Methylprednisolone 40 mg inj 40 mg $2.855
J1040 Methylprednisolone 80 MG inj 80 mg $5.463
J1050 Medroxyprogesterone acetate 1MG $0.242
J1100 Dexamethasone sodium phos 1 mg $0.119
J1110 Inj dihydroergotamine mesylt 1 mg $40.976
J1120 Acetazolamid sodium injection 500 mg $24.980
J1200 Diphenhydramine hcl injection 50 mg $0.574
J1240 Dimenhydrinate injection 50 mg $5.350
J1380 Estradiol valerate 10 mg $9.087
J1410 Inj estrogen conjugate 25 mg $163.736
J1450 Fluconazole 200 mg $4.036
J1459 inj IVIG privigen 500 mg $36.752
J1460 Gamma globulin 1 CC $24.783
j1557 Gammaplex injection 500mg $36.814
J1559 Hizentra injection 100 mg $7.679
J1560 Gamma globulin >10 CC $24.829
J1561 Gamunex, Gamunex-C, Gammaked 500 mg $39.504
J1566 Immune globulin, powder 500 mg $36.846
J1568 Octagam injection 500 mg $30.043
J1569 Gammagard liquid injection 500 mg $39.165
J1571 Hepagam b im injection 0.5mL $50.347
J1572 Flebogamma injection 500 mg $36.326
J1580 Garamycin gentamicin inj 80 mg $1.380
J1626 Granisetron hcl injecction 100 mcg $0.450
J1640 Hemin 1 mg $16.586
J1642 inj heparin sodium per 10 u 10 units $0.161
J1644 inj heparin sodium per 1000u 1000 units $0.161
J1670 Tetanus immune globulin 250 units $298.411
J1720 Hydrocortisone sodium succ inj 100 mg $5.133
J1750 Inj iron dextran 50 mg $11.926
J1756 Iron sucrose injection 1 mg $0.261
J1790 Droperidol injection 5 mg $2.141
J1800 Propanolol injection 1 mg $1.858
J1885 Ketorolac tromethamine inj 15 mg $0.639
J1940 Furosemide injection 20 mg $5.650
J1950 Leuprprolide acetate 3.75 mg $760.025
J1953 Levetiracetam injection 10 mg $0.134
J1956 Levofloxacin injection 250 mg $2.419
J1980 Hyoscyamine sulfate inj 0.25 mg $17.593
J2001 Lidocaine injection 10 mg $0.017
J2010 Lincomycin  injection 300 mg $8.302
J2150 Mannitol injection 50 ml $1.651
J2175 Meperedine hydrochl 100 mg $2.829
J2185 Meropenem 100 mg $1.133
J2353 Octreotide injection, depot 1 mg $139.085
J2354 Octreotide inj, non-depot 25 mcg $1.221
J2355 Oprelvekin injection 5 mg $276.228
J2405 Ondansetron hcl injection 1 mg $0.111
J2430 Pamidronate disodium 30 mg $13.895
J2510 Penecillin g procaine injection 600000 units $14.829
J2540 Penecillin g potassium injection 600000 units $0.781
J2543 Piperacillin / tazobactam 1.125 gm $1.583
J2550 Promethazine hcl injection 50 mg $1.581
J2590 Oxytocin injection 10 units $0.528
J2597 desmopressin acetate injection 1 mcg $5.153
J2765 Metoclopramide hcl injection 10 mg $0.818
J2778 Ranibizumab injection 0.1 mg $397.014
J2790 Rho d immune globulin injection 300 mcg $83.625
J2791 Rhophylac injection 100 iu $4.753
J2792 Rho(D) immune globulin h, sd 100 iu $18.738
J2916 Na ferric gluconate complex 12.5 mg $2.570
J2920 Methylprednisolone injection 40 mg $1.785
J2930 Methyprednisolone injection 125 mg $2.607
J2993 Reteplase injection 18.1 mg $2301.907
J2997 Alteplase recombinant 1 mg $60.316
J3000 Streptomycin injection 1 gm $10.470
J3095 Telavancin injection 10 mg $4.141
J3370 Vancomycin hcl injection 0.1 mg $2.007
J3420 Vitamin b 12 injection 1000 mcg $2.533
J3430 Vitamin k phytonadione injection 1 mg $1.023
J3475 Magnesium sulfate injection 500 mg $0.203
J3480 Potassium chloride injection 2 meq $0.013
J3489 Zoledronic Acid 1 mg $81.433
J7060 5% dextrose / water 500 mL $0.560
J7070 D5W infusion 1000 cc $2.431
J7100 Dextran 40 infusion 500 mL $23.112
J7120 Ringers lactate infusion 1000 cc $1.164
J7183 Wilate injection 1i.u.vwf:rco $0.902
J7185 Xyntha injection 1 iu $1.133
J7186 Antihemophilic VIII / vWF per factor VII iu $0.935
J7187 Humate-P, injection 1 iu $0.948
J7189 Factor VIIa 1 mcg $1.705
J7190 Factor VIII 1 iu $0.919
J7192 Factor VIII recombinant NOS 1 iu $1.134
J7193 FactorIX non-recombinant 1 iu $0.978
J7194 Factor IX complex 1 iu $1.103
J7195 Factor IX recombinant 1 iu $1.322
J7197 Antithrombin III injection 1 iu $3.148
J7198 Anti-inhibitor 1 iu $1.644
J9000 Doxorubicin hcl injection 10 mg $3.097
J9017 Arsenic trioxide injection 1 mg $49.222
J9020 Aparginase, NOS 10000 UNITS $64.565
J9025 Azacitidine injection 1 mg $4.934
J9031 Bcg live intavesical vac 1 ea $129.634
J9040 Bleomycin sulfate injection 15 units $20.963
J9041 Bortezomib injection 0.1 mg $45.571
J9042 Brentuximab vedotin inj 1MG $106.684
J9043 Cabazitaxel injection 1 mg $142.077
J9045 Carboplatin injection 50 mg $3.506
J9060 Cisplatin 10 mg injection 10 mg $2.283
J9070 Cyclophosphamine 100 mg $52.450
J9098 Cytarabine liposome injection 10 mg $544.509
J9100 Cytarabine hcl 100 mg $1.006
J9120 Dactinomycin injection 0.5 mg $645.752
J9130 Dacarbazine 100 mg $3.988
J9150 Daunorubicin injection 10 mg $25.450
J9155 Degarelix injection 1 mg $3.099
J9171 Docetaxel injection 1 mg $3.829
J9178 Epirubicin hcl injection 2 mg $1.276
J9179 Eribulin mesylate injection 0.1mg $98.239
J9181 Etoposide injection 10 mg $0.647
J9185 Fludarabine phosphate injection 50 mg $84.653
J9190 Fluoroucil injection 500 mg $1.893
J9200 Floxuridine injection 500 mg $78.260
J9201 Gemcitabine hcl injection 200 mg $7.259
J9206 Irinotecan injection 20 mg $5.148
J9208 ifosfomide injection 1 gm $34.173
J9209 Mesna injection 200 mg $2.848
J9211 Idarubicin hcl injection 5 mg $29.378
J9214 Interferon alfa-2b injection 1 mil units $20.662
J9217 Leuprolide acetate suspension 7.5 mg $206.784
J9218 Leuprolide acetate injection 1 mg $7.903
J9225 Vantas implant 50 mg $2980.709
J9226 Supprelin LA implant 50 mg $16875.984
J9228 Ipilimumab injection 1 mg $130.868
J9230 Mechlorethamine hcl injection 10 mg $154.699
J9250 Methotrexate sodium injection 5 mg $0.249
J9260 Methotrexate sodium injection 50 mg $2.465
J9261 Nelarabine injection 50 mg $134.699
J9263 Oxaliplatin 0.5 mg $0.564
J9264 Paclitaxel protein bound 1 mg $9.474
J9265 Paclitaxel injection 30 mg $4.722
J9266 Pegaspargase injection 1 ea $6007.380
J9268 Pentostatin injection 10 mg $1451.034
J9280 Mitomycin injection 5 mg $23.015
J9293 Mitoxantrone hydrochl 5 mg $34.096
J9300 Gemtuzumabozogamicin inj 5 mg $2742.591
J9302 Ofatumumab injection 10 mg $47.200
J9303 Panitumumab injection 10 mg $94.166
J9351 Topotecan injection 0.1 mg $2.189
J9360 Vinblastine sulfate injection 1 mg $1.902
J9370 Vincristine sulfate injection 1 mg $4.869
J9390 Vinorelbine tartrate injection 10 mg $10.612
P9041 Albumin (human) 5%, 50mL 50 mL $10.070
P9043 Plasma protein fraction 5%, 50 ml 50 mL $9.572
P9045 Albumin(human), 5%, 250 mL 250 mL $50.350
P9046 Albumin (human) 25%, 20 mL 20 mL $20.763
P9047 Albumin (human) 25%, 50 mL 50 mL $51.908
P9048 Plasmaprotein fraction 5%, 250 mL 250 mL $47.861
Q0162 Ondansetron oral 1mg $0.057
Q0163 Diphenhydramine HCI 50 mg $0.204
Q0164 Prochloreperazine maleate 5 mg $0.031
Q0166 Granisetron hcl 1 mg $1.773
Q0169 Promethazine HCI 12.5 mg $0.022
Q2035 Afluris vacc, 3yrs &>, im 0.5 mg $11.543
Q2037 Fluvirin vacc, 3 yrs & >. IM 0.5 mL $14.963
Q2038 Fluzone vacc, 3 yrs & >, im 0.5mL $12.044
Q2050 Doxorubicin inj 10mg $513.480