Table III Medicare Drug Fee Schedule*
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1 Table III Medicare Drug Fee Schedule* CY st Quarter Average Sales Price (ASP) Data Plus 6 percent *The current Medicare payment allowance limits are effective January 1 March 31, 2016 CY 2016 Effective Jan. 1 Through Mar. 31 ASP Plus 6 percent Code Description Code Dosage J0129 Abatacept 10mg $39.44 J0130 Abciximab injection 10mg $1, J0133 Acyclovir, 5 mg 5mg $0.07 J0171 Adrenaline epinephrine inject 0.1mg $0.13 J0207 Amifostine 500mg $ J0210 Methyldopate hcl injection 250mg $42.40 J0215 Alefacept 0.5mg $41.64 J0256 Alpha 1 proteinase inhibitor 10mg $4.59 J0280 Aminophyllin 250 MG inj 250MG $8.87 J0289 Amphotericin b liposome inj 10MG $18.18 J0295 Ampicillin sodium per 1.5 gm 1.5mg $2.27 J0360 Hydralazine hcl injection 20mg $10.49 CY 2016 Effective April 1 Through June 30 ASP Plus 6 percent CY 2016 Effective July 1 Through Sept. 30 ASP Plus 6 Percent
2 J0456 Azithromycin 500mg $3.56 J0461 Atropine sulfate injection 0.01mg $0.05 J0475 Baclofen 10 MG injection 10mg $ J0476 Baclofen 10 MG injection 50mg $76.39 J0480 Basiliximab 20mg $3, J0490 Belimumab 10mg $41.45 J0500 Dicyclomine injection 20mg $57.74 J0515 Inj benztropine mesylate 1mg $20.32 J0583 Bivalirudin 1mg $3.01 J0585 Botulinum toxin a per unit 1unit $5.58 J0587 Botulinum toxin type B 100units $11.28 J0592 Buprenorphine hydrochloride 0.1mg $3.00 J0595 Butorphanol tartrate 1 mg 1mg $2.39 J0600 Edetate calcium disodium inj 1000mg $5, J0610 Calcium gluconate injection 10ml $3.10 J0630 Calcitonin salmon injection 400units $1, J0636 Inj calcitriol per 0.1 mcg 0.1mcg $0.35 J0637 Caspofungin acetate 5mg $12.94 J0640 Leucovorin calcium injection 50mg $3.83 J0690 Cefazolin sodium injection 500mg $0.89 J0692 Cefepime HCI for injection 500mg $2.51 J0694 Cefoxitin sodium injection 1gm $4.89 J0696 Ceftriaxone sodium injection 250mg $0.77 J0697 Sterile cefuroxime injection 750mg $2.41 J0698 Cefotaxime sodium injection 1gm $3.14 J0702 Betamethasone acet&sod phosp 3mg/3mg $5.83 J0713 Inj ceftazidime per 500 mg 500mg $2.39 J0717 Certolizum Pegol Inj 1mg $6.46 J0720 Chloramphenicol sodium inject 1gm $31.74 J0725 Chorionic gonadotropin1000u 1,000units $20.20
3 J0740 Cidofovir injection 375mg $ J0743 Cilastatin sodium injection 250mg $4.54 J0770 Colistimethate sodium inj 150mg $10.40 J0780 Prochlorperazine injection 10mg $13.09 J0800 Corticotropin injection 40units $3, J0882 Darbepoetin alfa, non-esrd 1mcg $4.15 J0885 Non esrd epoetin alpha inj 1,000units $12.33 J0895 Deferoxamine mesylate inj 500mg $15.00 J0897 Denosumab injection 1 mg $15.48 J1000 Depo-estradiol cypionate inj 5mg $13.80 J1020 Methylprednisolone 20 MG inj 20mg $4.49 J1030 Methylprednisolone 40 MG inj 40mg $4.30 J1040 Methylprednisolone 80 MG inj 80mg $8.33 J1100 Dexamethasone sodium phos 1mg $0.13 J1110 Inj dihydroergotamine mesylt 1mg $76.74 J1120 Acetazolamid sodium injection 50mg $20.76 J1160 Digoxin injection 0.5mg $4.57 J1165 Phenytoin sodium injection 50mg $0.65 J1190 Dexrazoxane HCI injection 250mg $ J1200 Diphenhydramine hcl injection 50mg $0.49 J1205 Chlorothiazide sodium inj 500mg $ J1230 Methadone injection 10mg $10.26 J1245 Dipyridamole injection 10mg $0.81 J1250 Inj dobutamine HCL/250mg 250mg $5.54 J1260 Dolasetron mesylate 10mg $7.76 J1265 Dopamine injection 40mg $0.61 J1270 Injection, doxercalciferol 1mcg $0.92 J1325 Epoprostenol injection 0.5mg $15.47 J1335 Ertapenem injection 500mg $41.63 J1364 Erythro lactobionate /500 MG 500mg $48.39
4 J1410 Inj estrogen conjugate 25 MG 25mg $ J1430 Ethanolamine oleate 100 mg 100mg $ J1450 Fluconazole 200mg $4.82 J1566 Inj immune globulin, Iyophilzed 500mg $ mg J1570 Ganciclovir sodium injection 500mg $66.18 J1580 Garamycin gentamicin inj 80mg $1.25 J1610 Glucagon hydrochloride/1 MG 1mg $ J1626 Granisetron HCI injection 100mg $0.43 J1630 Haloperidol injection 5mg $1.52 J1631 Haloperidol decanoate inj 50mg $20.28 J1642 Inj heparin sodium per 10 u 10units $0.19 J1644 Inj heparin sodium per 1000 u 1000units $0.21 J1645 Dalteparin sodium 2500I.U. $15.59 J1650 Inj enoxaparin sodium 10mg $1.14 J1652 Fondaparinux sodium 05.mg $2.53 J1720 Hydrocortisone sodium succ i 100mg $7.50 J1740 Ibandronate sodium 1mg $ J1742 Ibutilide fumarate injection 1mg $94.25 J1745 Infliximab injection 10mg $79.90 J1756 Iron sucrose injection 1mg $0.26 J1786 Imuglucerase injection 10units $41.99 J1790 Droperidol injection 5mg $2.14 J1800 Propranolol injection 1mg $2.89 J1815 Insulin injection 5units $0.79 J1817 Insulin for insulin pump use 50units $8.35 J1940 Furosemide injection 20mg $2.89 J1950 Leuprolide acetate/3.75 MG 3.75mg $ J1955 Inj levocarnitine per 1 gm 1gm $17.43 J1956 Levofloxacin injection 250mg $2.39
5 J1980 Hyoscyamine sulfate inj 0.25mg $24.38 J2001 Lidocaine injection 10mg $0.01 J2010 Lincomycin injection 300mg $11.20 J2020 Linezolid injection 200mg $23.71 J2060 Lorazepam injection 2mg $0.75 J2150 Mannitol injection 50ml $1.60 J2185 Meropenem 100mg $1.31 J2210 Methylergonovin maleate inj 0.2mg $4.91 J2250 Inj midazolam hydrochloride 1mg $0.13 J2260 Inj milrinone lactate / 5 MG 5mg $3.20 J2300 Inj nalbuphine hydrochloride 10mg $2.37 J2310 Inj naloxone hydrochloride 1mg $27.99 J2353 Octreotide injection, depot 1mg $ J2354 Octreotide inj, non-depot 25mg $1.22 J2355 Oprelvekin injection 5mg $ J2370 Phenylephrine hcl injection 1ml $3.34 J2400 Chloroprocaine hcl injection 30ml $22.81 J2405 Ondansetron hcl injection 1mg $0.09 J2410 Oxymorphone hcl injection 1mg $2.84 J2430 Pamidronate disodium /30 MG 30mg $11.57 J2501 Paricalcitol 1mcg $0.95 J2505 Injection, pegfilgrastim 6mg 6mg $3, J2507 Pegloticase injection 1mg 1mg $1, J2510 Penicillin procaine inj 600,00units $22.52 J2515 Pentobarbital sodium inj 50mg $41.67 J2543 Piperacillin/tazobactam 1.125gm $2.59 J2550 Promethazine hcl injection 50mg $1.63 J2560 Phenobarbital sodium inj 120mg $29.19 J2597 Inj desmopressin acetate 1mcg $13.51 J2675 Inj progesterone per 50 MG 50mg $0.97
6 J2680 Fluphenazine decanoate 25 MG 25mg $22.26 J2690 Procainamide hcl injection 1gm $46.14 J2700 Oxacillin sodium injection 250mg $1.80 J2730 Pralidoxime chloride inj 1gm $87.66 J2760 Phentolaine mesylate 5mg $ J2765 Metoclopramide hcl injection 10mg $0.70 J2770 Quinupristin/dalfopristin 500mg $ J2780 Ranitidine hydrochloride 25mg $1.06 J2783 Rasburicase 0.5mg $ J2788 Rho d immune globulin 50 mcg 50mcg $24.39 J2792 Rho(D) immune globulin h, sd 100IU $20.22 J2795 Ropivacaine HCi injection 1mg $0.07 J2810 Inj theophylline 40mg $0.29 J2820 Sargramostim injection 50mcg $34.27 J2916 Na ferric gluconate complex 12.5mg $2.56 J2920 Methylprednisolone injection 40mg $2.89 J2930 Methylprednisolone injection 125mg $4.10 J2993 Reteplase injection 18.1mg $2, J2997 Alteplase recombinant 1mg $74.69 J3010 Fentanyl citrate injection 0.1mg $0.49 J3101 Tenecteplase injection 1mg $93.92 J3105 Terbutaline sulfate inj 1mg $0.84 J3230 Chlorpromazine hcl injection 50mg $19.20 J3240 Thyrotropin injection 0.9mg $1, J3250 Trimethobenzamide hcl inj 200mg $23.72 J3260 Tobramycin sulfate injection 80mg $2.61 J3262 Tocilizumab injection 1mg $4.00 J3285 Treprostinil, 1 mg 1mg $61.23 J3301 Triamcinolone acetonide inj 10mg $1.80 J3315 Triptorelin pamoate 3.75mg $238.97
7 J3360 Diazepam injection 5mg $6.64 J3370 Vancomycin hcl injection 500mg $3.86 J3396 Verteporfin injection 0.1mg $10.97 J3410 Hydroxyzine hcl injection 25mg $2.18 J3420 Vitamin B12 injection 1000mcg $2.63 J3430 Vitamin K phytonadione inj 1mg $2.73 J3465 Injection, voriconazale 10mg $3.88 J3475 Inj magnesium sulfate 500mg $0.22 J3480 Inj potassium chloride 2meg $0.14 J3485 Zidovudine 10mg $1.50 J3486 Ziprasidone mesylate 10mg $15.57 J3489 Zoledronic acid 1mg $27.52 J7030 Normal saline solution infus 1000cc $1.87 J7040 Normal saline solution infus 500ML $0.93 J7042 5% dextrose/normal saline 500ML $0.59 J7050 Normal saline solution infus 250cc $0.46 J7060 5% dextrose/water 500ML $1.83 J7070 D5w infusion 1000cc $3.57 J7100 Dextran 40 infusion 500ml $17.77 J7120 Ringers lactate infusion 1000cc $1.82 J7189 Factor viia recombinant 1mcg $1.96 J7190 Factor viia 1I.U. $0.95 J7192 Factor viia recombinant 1I.U. $1.17 J7193 Factor IX non-recombinant 1I.U. $1.09 J7194 Factor IX complex 1I.U. $1.21 J7195 Factor IX recombinant 1I.U. $1.45 J7197 Antithrombin iii injection 1I.U. $3.61 J7198 Anti-inhibitor 1I.U. $1.90 J7308 Aminolevulinic acid hcl top 354mg $ J7310 Ganciclovir long act implant 4.5mg $16,960.00
8 J7321 Hyalgan or Supartz, inj PER DOSE $88.11 J7323 Euflexxa, inj PER DOSE $ J7324 Orthovisc, inj PER DOSE $ J7325 Synvisc and Synvisc-One 1mg $13.12 J7500 Azathioprine oral 50mg 50mg $0.35 J7501 Azathioprine parental 100mg $ J7502 Cyclosporine oral 100 mg 100mg $3.36 J7504 Lymphocyte immune globulin 250mg $1, J7506 Prednisone oral 5mg $0.08 J7507 Tacrolimus oral per 1 MG 1MG $0.85 J7509 Methylprednisolone oral 4mg $0.32 J7511 Antithymocyte globulin rabbit 25mg $ J7515 Cyclosporine oral 25 mg 25mg $0.97 J7516 Cyclosporine parental 250mg 250mg $42.69 J7517 Mycophenolate mofetil oral 250mg $1.00 J7520 Sirolimus, oral 1mg $9.66 J7525 Tacrolimus injection 5mg $ J7608 Acetylcysteine inh sol u d 1gm $4.02 J7626 Budesonide inhalation sol 0.5mg $5.31 J7631 Cromolyn sodium inh sol u d 10mg $0.79 J7639 Dornase alpha inhal sol u d 1mg $38.98 J7644 Ipratropium bro minh sol u d 1mg $0.21 J7682 Tobramycin inhalation sol 300mg $55.60 J8510 Oral busulfan 2mg $12.34 J8520 Capecitabine, oral, 150 mg 150mg $5.23 J8521 Capecitabine, oral 500 mg 500mg $16.64 J8530 Cyclophosphamide oral 25 MG 25mg $3.67 J8560 Etoposide oral 50 MG 50mg $68.62 J8610 Methotrexate oral 2.5 MG 2.5mg $1.38 J8700 Temozolomide 5mg $3.61
9 J9000 Doxorubic hcl MG vl chemo 10mg $3.10 J9017 Arsenic trioxide 1mg $59.26 J9020 Asparaginase inj 10,000units $64.57 J9031 Bcg live intravesical vac Per installation $ J9040 Bleomycin sulfate inj 15units $21.19 J9045 Carboplatin inj 50mg $3.63 J9050 Carmustine injection 100mg $3, J9060 Cisplatin 10 MG inj 10mg $1.55 J9065 Inj cladribine per 1 MG 1mg $17.53 J9070 Cyclophosphamide 500 MG inj 100mg $48.67 J9100 Cytarabine hcl 100 MG inj 100mg $0.88 J9120 Dactinomycin actinomycin d 0.5mg $1, J9150 Daunorubicin 10mg $26.46 J9171 Docetaxel injection 1mg $2.59 J9178 Inj, epirubicin hcl, 2 mg 2mg $1.61 J9181 Etoposide 10 MG inj 10mg $0.63 J9185 Fludarabine phosphate inj 50mg $67.39 J9190 Fluorouracil injection 500mg $1.80 J9200 Floxuridine injection 500mg $69.59 J9201 Gemcitabine 200mg $8.71 J9202 Goserelin acetate implant 3.6mg $ J9206 Irinotecan injection 20mg $4.17 J9208 Ifosfomide injection 1gm $30.93 J9209 Mesna injection 200mg $4.15 J9211 Idarubicin hcl injection 5mg $39.05 J9214 Interferon alfa-2b inj 1 Mil Units $23.90 J9217 Leuprolide acetate suspension 7.5mg $ J9218 Leuprolide acetate inj 1mg $16.16 J9230 Mechlorethamine hcl inj 10mg $ J9245 Inj melphalan hydrochl 50 MG 50mg $1,604.05
10 J9250 Methotrexate sodium inj 5mg $0.23 J9260 Methotrexate sodium inj 50mg $2.30 J9263 Oxaliplatin 0.5mg $0.38 J9268 Pentostatin injection 10mg $1, J9280 Mitomycin 5 MG inj 5mg $ J9293 Mitoxantrone hydrochl / 5 MG 5mg $ J9310 Rituximab injection 100mg $ J9320 Streptozocin inj 1gm $ J9355 Trastuzumab 10mg $89.51 J9360 Vinblastine sulfate inj 1mg $2.98 J9370 Vincristine sulfate 1 MG inj 1mg $6.49 J9390 Vinorelbine tartrate/10 mg 10mg $11.00 J9395 Injection, Fulvestrant 25mg $93.58 Q0167 Dronabinol 2.5mg oral 2.5mg $1.63 This information is from the CMS website dated January 7, 2016.
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