Download 4th Quarter 2013

DME MAC Jurisdiction B
Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees
Effective 10/01/2013 through 12/31/2013
Revised per CR 8748
The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.
HCPCS CODE /
NDC NUMBER
G0333
J0133
J0285
J0287
J0288
J0289
J0895
J1170
J1250
J1265
J1325
J1455
J1459
J1557
J1559
J1561
J1561JB
J1562
J1566
J1568
J1569
J1569JB
J1570
J1572
J1815
J1817
J2175
J2260
J2270
J2271
J2275
J2278
DESCRIPTION
DOSAGE
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S);
INITIAL 30-DAY SUPPLY AS A BENEFICIARY
INJECTION, ACYCLOVIR
INJECTION, AMPHOTERICIN B
INJECTION, AMPHOTERICIN B LIPID COMPLEX
INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE
COMPLEX
INJECTION, AMPHOTERICIN B LIPOSOME
INJECTION, DEFEROXAMINE MESYLATE
INJECTION, HYDROMORPHONE
INJECTION, DOBUTAMINE HYDROCHLORIDE
INJECTION, DOPAMINE HCL
INJECTION, EPOPROSTENOL
INJECTION, FOSCARNET SODIUM
INJECTION, IMMUNE GLOBULIN (PRIVIGEN),
INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)
INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX),
INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)
INJECTION, IMMUNE GLOBULIN (HIZENTRA)
INJECTION, IMMUNE GLOBULIN, (GAMUNEXC/GAMMAKED), NON-LYOPHILIZED (E.G. LIQUID)
INJECTION, IMMUNE GLOBULIN, (GAMUNEXC/GAMMAKED), NON-LYOPHILIZED (E.G. LIQUID) [JB
modifier indicates drug being administered
subcutaneously]
INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN)
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS,
LYOPHILIZED (E.G. POWDER), NOT OTHERWISE
SPECIFIED
INJECTION, IMMUNE GLOBULIN, (OCTAGAM),
INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)
INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID),
NON-LYOPHILIZED, (E.G. LIQUID)
INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID),
NON-LYOPHILIZED, (E.G. LIQUID) [JB modifier indicates
drug being administered subcutaneously]
INJECTION, GANCICLOVIR SODIUM
INJECTION, IMMUNE GLOBULIN,
(FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NONLYOPHILIZED (E.G. LIQUID)
INJECTION, INSULIN
INSULIN FOR ADMINISTRATION THROUGH DME (I.E.,
INSULIN PUMP)
INJECTION, MEPERIDINE HYDROCHLORIDE
INJECTION, MILRINONE LACTATE
INJECTION, MORPHINE SULFATE
INJECTION, MORPHINE SULFATE
MORPHINE SULFATE, PRESERVATIVE FREE STERILE
SOLUTION
INJECTION, ZICONOTIDE
© Copyright 2016 CGS Administrators, LLC.
Page 1 of 6
FEE
$57.000
5 MG
50 MG
10 MG
$0.470
$10.280
$21.850
10 MG
$15.200
10 MG
500 MG
UP TO 4 MG
250 MG
40 MG
0.5 MG
1000 MG
$35.800
$15.630
$1.490
$4.740
$0.620
$12.640
$13.070
500 MG
$36.517
500 MG
$36.782
100 MG
$14.364
500 MG
$40.468
500 MG
$46.170
100 MG
$11.400
500 MG
$35.748
500 MG
$31.491
500 MG
$39.265
500 MG
$52.497
500 MG
$35.250
500 MG
$36.080
5 UNITS
$0.590
50 UNITS
$2.800
100 MG
5 MG
UP TO 10 MG
100 MG
$0.560
$51.580
$0.710
$11.070
10 MG
$4.390
1 MCG
$6.935
DME MAC Jurisdiction B
Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees
Effective 10/01/2013 through 12/31/2013
Revised per CR 8748
The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.
HCPCS CODE /
NDC NUMBER
DESCRIPTION
DOSAGE
FEE
J2545
PENTAMIDINE ISETHIONATE, INHALATION SOLUTION,
FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM
300 MG
J2920
INJECTION, METHYLPREDNISOLONE SODIUM
SUCCINATE
UP TO 40 MG
$1.741
UP TO 125 MG
$2.576
J2930
J3010
J3285
J7500
J7501
J7502
J7504
J7505
J7506
J7507
J7509
J7510
J7511
J7513
J7515
J7516
J7517
J7518
J7520
J7525
J7527
J7605KO
J7606KO
J7608KO
J7611
J7612
J7613KO
J7614KO
INJECTION, METHYLPREDNISOLONE SODIUM
SUCCINATE
INJECTION, FENTANYL CITRATE
INJECTION, TREPROSTINIL
AZATHIOPRINE, ORAL
AZATHIOPRINE, PARENTERAL
CYCLOSPORINE, ORAL
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE
GLOBULIN, EQUINE, PARENTERAL
MUROMONAB-CD3, PARENTERAL
PREDNISONE, ORAL
TACROLIMUS, ORAL
METHYLPREDNISOLONE, ORAL
PREDNISOLONE, ORAL
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE
GLOBULIN, RABBIT, PARENTERAL
DACLIZUMAB, PARENTERAL
CYCLOSPORINE, ORAL
CYCLOSPORINE, PARENTERAL
MYCOPHENOLATE MOFETIL, ORAL
MYCOPHENOLIC ACID, ORAL
SIROLIMUS, ORAL
TACROLIMUS, PARENTERAL
EVEROLIMUS, ORAL
ARFORMOTEROL, INHALATION SOLUTION, FDA
APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM
FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA
APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM
ACETYLCYSTEINE, INHALATION SOLUTION, FDAAPPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED
FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED
THROUGH DME, CONCENTRATED FORM
LEVALBUTEROL, INHALATION SOLUTION, FDAAPPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, CONCENTRATED FORM
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED
FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED
THROUGH DME, UNIT DOSE
LEVALBUTEROL, INHALATION SOLUTION, FDAAPPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE
© Copyright 2016 CGS Administrators, LLC.
Page 2 of 6
$82.924
0.1 MG
1 MG
50 MG
100 MG
100 MG
$0.700
$61.750
$0.124
$83.125
$3.180
250 MG
$721.063
5 MG
5 MG
1 MG
4 MG
5 MG
$1,156.078
$0.038
$1.716
$0.535
$0.035
25 MG
$569.528
25 MG
25 MG
250 MG
250 MG
180 MG
1 MG
5 MG
0.25 MG
$526.343
$0.885
$31.542
$1.032
$3.812
$13.280
$136.893
$6.475
15 MCG
$5.550
20 MCG
$6.300
1 GM
$1.961
1 MG
$0.103
0.5 MG
$0.229
1 MG
$0.049
0.5 MG
$0.123
DME MAC Jurisdiction B
Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees
Effective 10/01/2013 through 12/31/2013
Revised per CR 8748
The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.
HCPCS CODE /
NDC NUMBER
J7626KO
J7631KO
J7639KO
J7644KO
J7669KO
J7682KO
J7686KO
Q0162
DOSAGE
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE,
UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON1 UNIT
COMPOUNDED, ADMINISTERED THROUGH DME
J7620
J8501
J8520
J8521
J8530
J8540
J8610
J8650
J9000
J9040
J9065
J9100
J9190
J9200
J9208
J9263
J9265
J9355
J9360
J9370
J9390
DESCRIPTION
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED
FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED
THROUGH DME, UNIT DOSE FORM
CROMOLYN SODIUM, INHALATION SOLUTION, FDAAPPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM
DORNASE ALPHA, INHALATION SOLUTION, FDAAPPROVED FINAL PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM
IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDAAPPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM
METAPROTERENOL SULFATE, INHALATION SOLUTION,
FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM
TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED
FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE
FORM, ADMINISTERED THROUGH DME
TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED
FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED
THROUGH DME, UNIT DOSE FORM
APREPITANT, ORAL
CAPECITABINE, ORAL
CAPECITABINE, ORAL
CYCLOPHOSPHAMIDE; ORAL
DEXAMETHASONE, ORAL
METHOTREXATE; ORAL
NABILONE, ORAL
INJECTION, DOXORUBICIN HYDROCHLORIDE
INJECTION, BLEOMYCIN SULFATE
INJECTION, CLADRIBINE
INJECTION, CYTARABINE
INJECTION, FLUOROURACIL
INJECTION, FLOXURIDINE
INJECTION, IFOSFAMIDE
INJECTION, OXALIPLATIN
INJECTION, PACLITAXEL
INJECTION, TRASTUZUMAB
INJECTION, VINBLASTINE SULFATE
VINCRISTINE SULFATE
INJECTION, VINORELBINE TARTRATE
ONDANSETRON, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC
SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48
HOUR DOSAGE REGIMEN
© Copyright 2016 CGS Administrators, LLC.
Page 3 of 6
FEE
$0.180
UP TO 0.5 MG
$5.952
10 MG
$0.495
1 MG
$32.778
1 MG
$0.240
10 MG
$0.435
300 MG
$119.999
1.74 MG
$460.450
5 MG
150 MG
500 MG
25 MG
0.25 MG
2.5 MG
1 MG
10 MG
15 UNITS
1 MG
100 MG
500 MG
500 MG
1 GM
0.5 MG
30 MG
10 MG
1 MG
1 MG
10 MG
$6.688
$9.687
$32.191
$0.975
$0.178
$1.082
$27.066
$12.540
$289.370
$61.720
$8.190
$2.070
$136.800
$150.380
$9.446
$162.170
$58.130
$4.100
$33.980
$109.000
1 MG
$0.042
DME MAC Jurisdiction B
Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees
Effective 10/01/2013 through 12/31/2013
Revised per CR 8748
The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.
HCPCS CODE /
NDC NUMBER
DESCRIPTION
DOSAGE
FEE
Q0163
DIPHENHYDRAMINE HYDROCHLORIDE, ORAL, FDA
APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- 50 MG
EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT
TO EXCEED A 48 HOUR DOSAGE REGIMEN
$0.029
Q0164
PROCHLORPERAZINE MALEATE, ORAL, FDA APPROVED
PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE
THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT 5MG
TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED
A 48 HOUR DOSAGE REGIMEN
$0.026
Q0165
PROCHLORPERAZINE MALEATE, ORAL, FDA APPROVED
PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE
THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT 10 MG
TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED
A 48 HOUR DOSAGE REGIMEN
$0.036
Q0166
GRANISETRON HYDROCHLORIDE, ORAL, FDA
APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- 1 MG
EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT
TO EXCEED A 24 HOUR DOSAGE REGIMEN
$2.539
Q0167
Q0168
DRONABINOL, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC
SUBSTITUTE FOR AN IV ANTI-EMETIC AT TIME OF
CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48
HOUR DOSAGE REGIMEN
DRONABINOL, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC
SUBSTITUTE FOR AN IV ANTI-EMETIC AT TIME OF
CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48
HOUR DOSAGE REGIMEN
2.5 MG
$3.346
5 MG
$6.822
Q0169
PROMETHAZINE HYDROCHLORIDE, ORAL, FDA
APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- 12.5 MG
EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT
TO EXCEED A 48 HOUR DOSAGE REGIMEN
$0.062
Q0170
PROMETHAZINE HYDROCHLORIDE, ORAL, FDA
APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- 25 MG
EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT
TO EXCEED A 48 HOUR DOSAGE REGIMEN
$0.085
Q0171
CHLORPROMAZINE HYDROCHLORIDE, ORAL, FDA
APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- 10 MG
EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT
TO EXCEED A 48 HOUR DOSAGE REGIMEN
$0.801
© Copyright 2016 CGS Administrators, LLC.
Page 4 of 6
DME MAC Jurisdiction B
Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees
Effective 10/01/2013 through 12/31/2013
Revised per CR 8748
The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.
HCPCS CODE /
NDC NUMBER
DESCRIPTION
DOSAGE
FEE
Q0172
CHLORPROMAZINE HYDROCHLORIDE, ORAL, FDA
APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- 25 MG
EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT
TO EXCEED A 48 HOUR DOSAGE REGIMEN
$1.145
Q0173
TRIMETHOBENZAMIDE HYDROCHLORIDE, ORAL, FDA
APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- 250 MG
EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT
TO EXCEED A 48 HOUR DOSAGE REGIMEN
$0.349
Q0174
THIETHYLPERAZINE MALEATE, ORAL, FDA APPROVED
PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE
THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT 10 MG
TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED
A 48 HOUR DOSAGE REGIMEN
Q0175
PERPHENAZINE, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC
SUBSTITUTE FOR AN IV ANTI-EMETIC AT TIME OF
CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48
HOUR DOSAGE REGIMEN
4 MG
$1.337
Q0176
PERPHENAZINE, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC
SUBSTITUTE FOR AN IV ANTI-EMETIC AT TIME OF
CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48
HOUR DOSAGE REGIMEN
8 MG
$1.746
Q0177
HYDROXYZINE PAMOATE, ORAL, FDA APPROVED
PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE
THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT 25 MG
TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED
A 48 HOUR DOSAGE REGIMEN
$0.158
Q0178
HYDROXYZINE PAMOATE, ORAL, FDA APPROVED
PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE
THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT 50 MG
TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED
A 48 HOUR DOSAGE REGIMEN
$0.164
Q0180
DOLASETRON MESYLATE, ORAL, FDA APPROVED
PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE
THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT 100 MG
TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED
A 24 HOUR DOSAGE REGIMEN
$69.470
Q0510
PHARMACY SUPPLY FEE FOR INITIAL
IMMUNOSUPPRESSIVE DRUG(S), FIRST MONTH
FOLLOWING TRANSPLANT
$50.000
© Copyright 2016 CGS Administrators, LLC.
Page 5 of 6
TBD*
DME MAC Jurisdiction B
Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees
Effective 10/01/2013 through 12/31/2013
Revised per CR 8748
The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.
HCPCS CODE /
NDC NUMBER
DESCRIPTION
DOSAGE
FEE
Q0511
PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL
ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR
THE FIRST PRESCRIPTION IN A 30-DAY PERIOD
$24.000
Q0512
PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL
ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR A
SUBSEQUENT PRESCRIPTION IN A 30-DAY PERIOD
$16.000
Q0513
Q0514
Q4074
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
NDC number
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S);
PER 30 DAYS
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S);
PER 90 DAYS
ILOPORST, INHALATION SOLUTION, FDA-APPROVED
FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED
THROUGH DME, UNIT DOSE FORM
BUSULFAN, ORAL
CAPECITABINE, ORAL
CAPECITABINE, ORAL
CYCLOPHOSPHAMIDE, ORAL
CYCLOPHOSPHAMIDE, ORAL
ETOPOSIDE, ORAL
FLUDARABINE PHOSPHATE, ORAL
MELPHALAN, ORAL
METHOTREXATE, ORAL
METHOTREXATE, ORAL
METHOTREXATE, ORAL
METHOTREXATE, ORAL
METHOTREXATE, ORAL
TEMOZOLOMIDE, ORAL
TEMOZOLOMIDE, ORAL
TEMOZOLOMIDE, ORAL
TEMOZOLOMIDE, ORAL
TOPOTECAN, ORAL
$33.000
$66.000
UP TO 20 MCG
2 MG
150 MG
500 MG
25 MG
50 MG
50 MG
10 MG
2 MG
2.5 MG
5 MG
7.5 MG
10 MG
15 MG
5 MG
20 MG
100 MG
250 MG
0.25 MG
*To Be Developed (TBD) indicates the claim will be developed for an invoice on the drug billed.
© Copyright 2016 CGS Administrators, LLC.
Page 6 of 6
$77.380
$11.029
$9.687
$32.191
$0.975
$1.950
$55.677
$81.772
$8.734
$1.082
$2.164
$3.246
$4.328
$6.492
$11.558
$46.232
$231.160
$577.900
$89.128