• 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.
Page 3 * 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
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 4.896 - - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 3.401 - - - - - -
J0594 - injection, busulfan, 1 mg 1 MG 37.286 - - - - - -
J0595 - Injection, butorphanol tartrate, 1 mg 1 MG 2.4 - - - - - -
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 46.63 - - - - - -
J0598 - Injection, c-1 esterase inhibitor (human), cinryze, 10 units 10 UNITS 55.549 - - - - - -
J0600 - Injection, edetate calcium disodium, up to 1000 mg 1000 MG 5594.422 - - - - - -
J0610 - Injection, calcium gluconate (fresenius kabi), per 10 ml 10 ML 3.514 - - - - - -
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 2301.567 - - - - - -
J0636 - Injection, calcitriol, 0.1 mcg 0.1 MCG 0.456 - - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 11.649 - - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 92.51 - - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 3.092 - - - - - -
J0641 - Injection, levoleucovorin, not otherwise specified, 0.5 mg 0.5 MG 0.688 - - 95% 1.49 - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 2.736 - - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 1.003 - - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 2.452 - - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 4.315 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.698 - - 95% 0.75 - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 2.638 - - - - - -
J0698 - Injection, cefotaxime sodium, per gm 1 GM 1.528 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.055 - - 95% 4.74 - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 2.456 - - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 2.237 - - - - - -
J0717 - Injection, certolizumab pegol, 1 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) 1 MG 7.38 - - - - - -
* Effective January 1, 2017 through March 31, 2017

Drugs not otherwise classified - January 2017

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 (Average Sale Price) Drug Pricing History