• 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 2 * 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
J0285 - Injection, amphotericin b, 50 mg 50 MG 30.244 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 14.496 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 19.774 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 1.259 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 3.009 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.498 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 4.568 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 4.592 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.266 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.055 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 45.28 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 167.244 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 76.521 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3341.06 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.834 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 41.937 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 69.247 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 25.776 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 8.508 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 10.659 - - - - - -
J0570 - Buprenorphine implant, 74.2 mg 74.2 MG 1280.518 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 1.333 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 5.942 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 7.796 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 11.688 - - 95% 15.63 - -
* 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