ASP Drug Pricing - (1st Quarter)
January 2017
Payment Allowance Limits for Medicare Part B Drugs

  • 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 4 * 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
J0720 - Injection, chloramphenicol sodium succinate, up to 1 gm 1 GM 40.117 - - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 24.037 - - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 13.545 - - 95% 12.64 - -
J0740 - Injection, cidofovir, 375 mg 375 MG 509.41 - - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 6.876 - - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 1.46 - - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 11.044 - - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 41.149 - - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 12.171 - - - - - -
J0795 - Injection, corticorelin ovine triflutate, 1 microgram 1 MCG 8.121 - - - - - -
J0800 - Injection, corticotropin, up to 40 units 40 UNITS 3536.424 - - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 38.433 - - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 2670.235 - - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1127.626 - - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 14.89 - - - - - -
J0878 - Injection, daptomycin, 1 mg 1 MG 0.894 - - - - - -
J0881 - Injection, darbepoetin alfa, 1 microgram (non-esrd use) 1 MCG 3.852 - - - - - -
J0882 - Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) 1 MCG 3.852 - - - - - -
J0885 - Injection, epoetin alfa, (for non-esrd use), 1000 units 1000 UNITS 12.32 - - - - - -
J0887 - Injection, epoetin beta, 1 microgram, (for esrd on dialysis) 1 MCG 1.565 - - - - - -
J0888 - Injection, epoetin beta, 1 microgram, (for non esrd use) 1 MCG 1.565 - - - - - -
J0894 - Injection, decitabine, 1 mg 1 MG 19.661 - - - - - -
J0895 - Injection, deferoxamine mesylate, 500 mg 500 MG 8.714 - - - - - -
J0897 - Injection, denosumab, 1 mg 1 MG 16.517 - - - - - -
J1000 - Injection, depo-estradiol cypionate, up to 5 mg 5 MG 17.768 - - 95% 35.25 - -
* 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