Maximum Allowed Units List
KEY | HCPCS Code | Code Description | MAU | Release Date | Reassesment Date |
|---|---|---|---|---|---|
J0129 | Injection, abatacept, 10 mg | 100 | 10/16/2008 | ||
J0150 | Injection, adenosine for therapeutic use, 6 mg | 5 | 10/16/2008 | 7/1/2010 | |
J0152 | Injection, adenosine for diagnostic use, 30 mg | 4 | 10/16/2008 | ||
J0170 | Injection, adrenalin, epinephrine, up to 1 ml ampul | 2 | 10/16/2008 | ||
J0180 | Injection, agalsidase beta, 1 mg | 105 | 10/16/2008 | ||
J0207 | Injection, amifostine, 500 mg | 5 | 10/16/2008 | ||
J0215 | Injection, alefacept, 0.5 mg | 30 | 10/16/2008 | ||
5 | J0256 | Injection, alpha 1-proteinase inhibitor-human, 10 mg | 3,000 | 10/16/2008 | 4/10/2009 |
J0270 | Injection, alprostadil, 1.25 mcg | 1 | 10/16/2008 | ||
J0275 | Alprostadil urethral suppository | 1 | 10/16/2008 | ||
J0278 | Injection, amikacin sulfate, 100 mg | 6 | 10/16/2008 | ||
J0280 | Injection, aminophylline, up to 250 mg | 1 | 10/16/2008 | ||
J0282 | Injection, amiodarone hydrochloride, 30 mg | 20 | 10/16/2008 | ||
J0285 | Injection, amphotericin B, 50 mg | 1 | 10/16/2008 | ||
| J0288 | Injection, amphotericin B cholesteryl sulfate complex, 10 mg | 45 | 7/17/2009 | ||
J0289 | Injection, amphotericin B liposome, 10 mg | 30 | 10/16/2008 | ||
J0290 | Injection, ampicillin sodium, 500 mg | 4 | 10/16/2008 | ||
J0295 | Injection, ampicillin sodium/sulbactam sodium, per 1.5 gram | 4 | 10/16/2008 | ||
J0360 | Injection, hydralazine HCl, up to 20 mg | 1 | 10/16/2008 | ||
J0390 | Injection, chloroquine HCl, up to 250 mg | 4 | 10/16/2008 | ||
J0456 | Injection, azithromycin, 500 mg | 1 | 10/16/2008 | ||
9 | J0460 | Injection, atropine sulfate, up to 0.3 mg | 4 | 10/16/2008 | |
| J0461 | Injection, atropine sulfate, up to 0.01 mg | 120 | 1/1/2010 | ||
5 | J0475 | Injection, baclofen, 10 mg | 8 | 10/16/2008 | |
J0476 | Injection, baclofen, 50 mcg for intrathecal trial | 2 | 10/16/2008 | ||
J0500 | Injection, dicyclomine HCl, up to 20 mg | 1 | 10/16/2008 | ||
J0515 | Injection, benztropine mesylate, per 1 mg | 2 | 10/16/2008 | ||
9 | J0530 | Injection, penicillin G benzathine and penicillin G procaine, up to 600,000 units | 2 | 10/16/2008 | |
9 | J0540 | Injection, penicillin G benzathine and penicillin G procaine, up to 1,200,000 units | 2 | 10/16/2008 | |
9 | J0550 | Injection, penicillin G benzathine and penicillin G procaine, up to 2,400,000 units | 1 | 10/16/2008 | |
| J0559 | Injection, penicillin G benzathine and penicillin G procaine, 2500 units | 960 | 1/1/2010 | ||
J0560 | Injection, penicillin G benzathine, up to 600,000 units | 4 | 10/16/2008 | 7/1/2010 | |
J0570 | Injection, penicillin G benzathine, up to 1,200,000 units | 2 | 10/16/2008 | ||
J0580 | Injection, penicillin G benzathine, up to 2,400,000 units | 1 | 10/16/2008 | ||
J0583 | Injection, bivalirudin, 1 mg | 250 | 10/16/2008 | 7/1/2010 | |
J0585 | Botulinum toxin type A, per unit | 600 | 11/18/2008 | 12/31/2008 | |
| J0586 | Injection, abobotulinumtoxina, 5 units | 200 | 1/1/2010 | ||
J0587 | Botulinum toxin type B, per 100 units | 250 | 10/16/2008 | 6/1/2010 | |
J0592 | Injection, buprenorphine hydrochloride, 0.1mg | 3 | 10/16/2008 | ||
J0595 | Injection, butorphanol tartrate, 1 mg | 4 | 10/16/2008 | ||
| J0598 | Injection, C1 esterase inhibitor (human), 10 units | 100 | 1/1/2010 | ||
J0600 | Injection, edetate calcium disodium, up to 1000 mg | 3 | 10/16/2008 | 7/1/2010 | |
J0610 | Injection, calcium gluconate, per 10 ml | 2 | 10/16/2008 | ||
J0637 | Injection, caspofungin acetate, 5 mg | 14 | 10/16/2008 | ||
J0640 | Injection, leucovorin calcium, per 50 mg | 24 | 10/16/2008 | ||
8 | J0641 | Injection, levoleucovorin calcium, 0.5 mg | 200 | 12/16/2008 | |
J0670 | Injection, mepivacaine HCl, per 10 ml | 4 | 10/16/2008 | ||
J0690 | Injection, cefazolin sodium, 500 mg | 12 | 10/16/2008 | 6/1/2010 | |
J0692 | Injection, cefepime hydrochloride, 500 mg | 8 | 10/16/2008 | ||
J0694 | Injection, cefoxitin sodium, 1 gram | 8 | 10/16/2008 | ||
J0696 | Injection, ceftriaxone sodium, per 250 mg | 16 | 10/16/2008 | ||
J0697 | Injection, sterile cefuroxime sodium, per 750 mg | 4 | 10/16/2008 | ||
J0698 | Injection, cefotaxime sodium, per gm | 6 | 10/16/2008 | ||
J0702 | Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate, per 3 mg | 4 | 10/16/2008 | Denied | |
J0704 | Injection, betamethasone sodium phosphate, per 4 mg | 5 | 10/16/2008 | ||
J0713 | Injection, ceftazidime, per 500 mg | 12 | 10/16/2008 | 6/1/2010 | |
J0715 | Injection, ceftizoxime sodium, per 500 mg | 8 | 11/7/2008 | ||
| J0718 | Injection, certolizumab pegol, 1 mg | 400 | 1/1/2010 | Removed: self administered drug list | |
J0720 | Injection, chloramphenicol sodium succinate, up to 1 gm | 6 | 11/7/2008 | ||
5 | J0735 | Injection, clonidine hydrochloride, 1 mg | 2 | 11/7/2008 | 7/1/2010 |
J0743 | Injection, cilastatin sodium; imipenem, per 250 mg | 8 | 11/7/2008 | ||
J0744 | Injection, ciprofloxacin for intravenous infusion, 200 mg | 6 | 11/7/2008 | ||
J0780 | Injection, prochlorperazine, up to 10 mg | 4 | 11/7/2008 | ||
J0800 | Injection, corticotropin, up to 40 units | 2 | 11/7/2008 | ||
| J0833 | Injection, cosyntropin, not otherwise specified, 0.25 mg | 3 | 1/1/2010 | ||
| J0834 | Injection, cosyntropin, (cortrosyn), 0.25 mg | 3 | 1/1/2010 | ||
9 | J0835 | Injection, cosyntropin, per 0.25 mg | 1 | 11/7/2008 | |
J0878 | Injection, daptomycin, 1 mg | 1000 | 11/7/2008 | ||
J0881 | Injection, darbepoetin alfa, 1 microgram (non-ESRD use) | 500 | 12/16/2008 | ||
J0882 | Injection, darbepoetin alfa, 1 microgram (for ESRD on dialysis) | 400 | 12/16/2008 | 7/1/2009 | |
J0885 | Injection, epoetin alfa, (for non-ESRD use), 1000 units | 60 | 12/16/2008 | ||
J0886 | Injection, epoetin alfa, 1000 units (for ESRD on dialysis) | 45 | 12/16/2008 | ||
J0894 | Injection, decitabine, 1 mg | 100 | 11/7/2008 | ||
J0895 | Injection, deferoxamine mesylate, 500 mg | 6 | 11/7/2008 | ||
J0900 | Injection, testosterone enanthate and estradiol valerate, up to 1 cc | 1 | 11/7/2008 | 4/1/2010 | |
J0945 | Injection, brompheniramine maleate, per 10 mg | 2 | 11/7/2008 | ||
J0970 | Injection, estradiol valerate, up to 40 mg | 1 | 11/7/2008 | ||
J1000 | Injection, depo-estradiol cypionate, up to 5 mg | 1 | 11/7/2008 | ||
J1020 | Injection, methylprednisolone acetate, 20 mg | 6 | 11/7/2008 | ||
J1030 | Injection, methylprednisolone acetate, 40 mg | 4 | 11/7/2008 | ||
J1040 | Injection, methylprednisolone acetate, 80 mg | 3 | 11/7/2008 | ||
J1051 | Injection, medroxyprogesterone acetate, 50 mg | 8 | 11/7/2008 | ||
2 | J1055 | Injection, medroxyprogesterone acetate for contraceptive use, 150 mg | 0 | 11/7/2008 | |
J1060 | Injection, testosterone cypionate and estradiol cypionate, up to 1 ml | 1 | 11/7/2008 | 4/1/2010 | |
J1070 | Injection, testosterone cypionate, up to 100 mg | 4 | 11/7/2008 | ||
J1080 | Injection, testosterone cypionate, 1 cc, 200 mg | 2 | 11/7/2008 | ||
J1094 | Injection, dexamethasone acetate, 1 mg | 16 | 11/7/2008 | ||
J1100 | Injection, dexamethasone sodium phosphate, 1 mg | 110 | 11/7/2008 | ||
J1110 | Injection, dihydroergotamine mesylate, per 1 mg | 3 | 11/7/2008 | ||
J1120 | Injection, acetazolamide sodium, up to 500 mg | 2 | 11/7/2008 | ||
J1160 | Injection, digoxin, up to 0.5 mg | 2 | 11/7/2008 | ||
J1162 | Injection, digoxin immune fab (ovine), per vial | 6 | 11/7/2008 | 7/1/2010 | |
J1165 | Injection, phenytoin sodium, per 50 mg | 35 | 11/7/2008 | ||
5 | J1170 | Injection, hydromorphone, up to 4 mg | 300 | 11/7/2008 | |
J1180 | Injection, dyphylline, up to 500 mg | 1 | 11/7/2008 | ||
J1190 | Injection, dexrazoxane hydrochloride, per 250 mg | 5 | 11/7/2008 | ||
J1200 | Injection, diphenhydramine HCl, up to 50 mg | 8 | 11/7/2008 | ||
J1205 | Injection, chlorothiazide sodium, per 500 mg | 4 | 11/7/2008 | ||
J1212 | Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml | 1 | 11/7/2008 | ||
5 | J1230 | Injection, methadone HCl, up to 10 mg | 10 | 11/7/2008 | |
J1240 | Injection, dimenhydrinate, up to 50 mg | 1 | 11/7/2008 | ||
J1245 | Injection, dipyridamole, per 10 mg | 6 | 11/7/2008 | ||
| J1250 | Injection, dobutamine hydrochloride, per 250 mg | 2 | 7/17/2009 | ||
| J1260 | Injection, dolasetron mesylate, 10 mg | 20 | 7/17/2009 | ||
8 | J1267 | Injection, doripenem, 10 mg | 100 | 12/16/2008 | |
| J1300 | Injection, eculizumab, 10 mg | 90 | 7/17/2009 | ||
J1325 | Injection, epoprostenol, 0.5 mg | 1 | 12/16/2008 | 7/1/2010 | |
J1327 | Injection, eptifibatide, 5 mg | 4 | 12/16/2008 | ||
4 | J1330 | Injection, ergonovine maleate, up to 0.2 mg | 0 | 11/21/2008 | |
J1335 | Injection, ertapenem sodium, 500 mg | 2 | 11/14/2008 | ||
J1364 | Injection, erythromycin lactobionate, per 500 mg | 5 | 12/16/2008 | ||
J1380 | Injection, estradiol valerate, up to 10 mg | 3 | 11/14/2008 | ||
J1390 | Injection, estradiol valerate, up to 20 mg | 2 | 11/14/2008 | ||
J1410 | Injection, estrogen conjugated, per 25 mg | 2 | 12/16/2008 | ||
J1435 | Injection, estrone, per 1 mg | 1 | 12/16/2008 | 7/1/2010 | |
J1440 | Injection, filgrastim (G-CSF), 300 mcg | 4 | 12/3/2008 | ||
J1441 | Injection, filgrastim (G-CSF), 480 mcg | 3 | 11/7/2008 | ||
J1450 | Injection, fluconazole, 200 mg | 6 | 11/14/2008 | ||
8 | J1453 | Injection, fosaprepitant, 1 mg | 115 | 12/16/2008 | |
8 | J1459 | Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg | 220 | 12/16/2008 | |
| J1460 | Injection, gamma globulin, intramuscular, 1cc | 1 | 4/1/2010 | ||
J1470 | Injection, gamma globulin; intramuscular, 2 cc | 1 | 11/14/2008 | ||
| J1480 | Injection, gamma globulin, intramuscular, 3 cc | 1 | 4/1/2010 | ||
| J1490 | Injection, gamma globulin, intramuscular, 4 cc | 1 | 4/1/2010 | ||
| J1500 | Injection, gamma globulin, intramuscular, 5 cc | 1 | 4/1/2010 | ||
| J1510 | Injection, gamma globulin, intramuscular, 6 cc | 1 | 4/1/2010 | ||
| J1520 | Injection, gamma globulin; intramuscular, 7 cc (gama stan ds) | 1 | 7/17/2009 | 4/1/2010 | |
| J1530 | Injection, gamma globulin, intramuscular, 8 cc | 1 | 4/1/2010 | ||
| J1540 | Injection, gamma globulin, intramuscular, 9 cc | 1 | 4/1/2010 | ||
J1550 | Injection, gamma globulin; intramuscular, 10 cc | 1 | 11/14/2008 | 4/1/2010 | |
| J1560 | Injection, gamma globulin, intramuscular, over 10 cc | 1 | 4/1/2010 | ||
| J1561 | Injection, immune globulin, (gamunex), intravenous, non-lyophilized (e.g., liquid), 500 mg | 440 | 7/17/2009 | ||
| J1562 | Injection, immune globulin, (vivaglobin), 100 mg | 220 | 7/17/2009 | ||
J1566 | Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg | 440 | 12/16/2008 | ||
| J1568 | Injection, immune globulin, (octagam), intravenous, non-lyophilized, (e.g., liquid), 500 mg | 440 | 7/17/2009 | 12/28/2009 | |
| J1569 | Injection, immune globulin, (gammagard liquid), intravenous, non-lyophilized, (e.g., liquid), 500 mg | 440 | 7/17/2009 | 12/28/2009 | |
| J1570 | Injection, ganciclovir sodium, 500 mg | 2 | 7/17/2009 | ||
J1580 | Injection, garamycin, gentamicin, up to 80 mg | 5 | 12/16/2008 | ||
4 | J1590 | Injection, gatifloxacin, 10 mg | 0 | 11/14/2008 | |
J1600 | Injection, gold sodium thiomalate, up to 50 mg | 1 | 11/14/2008 | ||
J1610 | Injection, glucagon hydrochloride, per 1 mg | 1 | 11/14/2008 | ||
J1626 | Injection, granisetron hydrochloride, 100 mcg | 11 | 12/3/2008 | ||
J1630 | Injection, haloperidol, up to 5 mg | 5 | 11/14/2008 | 7/1/2010 | |
J1631 | Injection, haloperidol decanoate, per 50 mg | 2 | 11/14/2008 | ||
J1640 | Injection, hemin, 1 mg | 660 | 12/3/2008 | ||
J1642 | Injection, heparin sodium, (heparin lock flush), per 10 units | 4 | 11/14/2008 | ||
J1644 | Injection, heparin sodium, per 1,000 units | 40 | 11/14/2008 | ||
J1645 | Injection, dalteparin sodium, per 2500 IU | 9 | 12/3/2008 | ||
J1650 | Injection, enoxaparin sodium, 10 mg | 17 | 12/3/2008 | 2/27/2009 | |
J1652 | Injection, fondaparinux sodium, 0.5 mg | 20 | 11/14/2008 | ||
J1655 | Injection, tinzaparin sodium, 1000 IU | 28 | 12/16/2008 | ||
J1670 | Injection, tetanus immune globulin, human, up to 250 units | 1 | 11/14/2008 | ||
| 5 | J1680 | Injection, human fibrinogen concentrate, 100 mg | 78 | 1/1/2010 | |
4 | J1710 | Injection, hydrocortisone sodium phosphate, up to 50 mg | 0 | 11/21/2008 | |
J1720 | Injection, hydrocortisone sodium succinate, up to 100 mg | 110 | 12/16/2008 | ||
| J1740 | Injection, ibandronate sodium, 1 mg | 3 | 7/17/2009 | ||
| J1743 | Injection, idursulfase, 1 mg | 55 | 7/17/2009 | ||
J1745 | Injection, infliximab, 10 mg | 110 | 11/14/2008 | 12/2/2008 | |
8 | J1750 | Injection, iron dextran, 50 mg | 90 | 12/16/2008 | |
7 | J1751 | Injection, iron dextran 165, 50 mg | 90 | 12/16/2008 | |
7 | J1752 | Injection, iron dextran 267, 50 mg | 90 | 12/16/2008 | |
J1756 | Injection, iron sucrose, 1 mg | 500 | 12/3/2008 | 5/1/2009 | |
5 | J1785 | Injection, imiglucerase, per unit | 6600 | 12/16/2008 | |
J1790 | Injection, droperidol, up to 5 mg | 2 | 11/14/2008 | 7/1/2010 | |
J1800 | Injection, propranolol HCl, up to 1 mg | 6 | 12/16/2008 | ||
3 | J1815 | Injection, insulin, per 5 units | 0 | 11/14/2008 | |
J1817 | Insulin for administration through DME (i.e., Insulin pump) per 50 units | 5 | 12/16/2008 | ||
| J1840 | Injection, kanamycin sulfate, up to 500 mg | 2 | 7/17/2009 | ||
| J1850 | Injection, kanamycin sulfate, up to 75 mg | 4 | 7/1/2010 | ||
J1885 | Injection, ketorolac tromethamine, per 15 mg | 8 | 11/14/2008 | ||
8 | J1930 | Injection, lanreotide, 1 mg | 120 | 12/16/2008 | |
J1940 | Injection, furosemide, up to 20 mg | 8 | 12/3/2008 | 6/1/2010 | |
J1950 | Injection, leuprolide acetate (for depot suspension), per 3.75 mg | 1 | 12/3/2008 | ||
8 | J1953 | Injection, levetiracetam, 10 mg | 150 | 12/16/2008 | |
J1956 | Injection, levofloxacin, 250 mg | 3 | 11/14/2008 |
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