• Note 1: Payment allowance limits subject to the ASP methodology are based on 3Q16 ASP data.
  • Note 2: 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.
Drug Pricing Drugs Not Otherwise Classified
Page 1 * Effective January 1, 2017 through March 31, 2017
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
A9575 - Injection, gadoterate meglumine, 0.1 ml 0.1 ml 0.204 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.626 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.074 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 2.026 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.818 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.018 - - - - - -
A9583 - Injection, gadofosveset trisodium, 1 ml 1 ML 18.112 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.385 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0129 - Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 10 MG 45.88 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1147.524 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.533 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.075 - - - - - -
J0135 - Injection, adalimumab, 20 mg 20 MG 909.215 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.601 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.336 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 980.381 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 164.796 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1750.714 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 412.27 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 159.732 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.851 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.367 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.766 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 9.044 - - - - - -
* Effective January 1, 2017 through March 31, 2017

Drugs not otherwise classified

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2017 through March 31, 2017

Drug name Dosage Payment limit Notes
Bumetanide 0.25 MG 0.258
Bupivacaine 1 ML 0.086
Clevidipine Butyrate 1 MG 3.041
Clindamycin Phosphate 150 MG 0.992
Coagulation Factor IX (Recombinant) (Ixinity) I IU 1.41
Diltiazem Hydrochloride 5 MG 0.196
Doxycycline Hyclate 100 MG 18.02
Esmolol Hydrochloride 10 MG 1.027
Famotidine 10 MG 0.38
Flumazenil 0.1 MG 0.752
Folic Acid 5 MG 2.733
Glucarpidase 10 UNITS 284.081
Glycopyrrolate injection 0.2 MG 6.369
Hexaminolevulinate HCl 100 mg, per study dose 959.067
Integra Meshed Bilayer Wound Matrix 1 SQ CM 55.731
Labetalol Hcl 5 MG 0.161
Metoprolol Tartrate 1 MG 0.155
Metronidazole inj 500 MG 1.125
Nitroglycerin 5 MG 0.947
Olanzapine short acting intramuscular injection 0.5 MG 1.225
Paliperidone Palmitate (Invega Trinza) 1 MG 8.137
Rifampin 600 MG 122.599
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.436
Sulfamethoxazole-Trimethoprim 400-80 MG 0.76
Vasopressin 20 UNITS 129.581

ASP Drug Pricing History