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 5 * 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
J1020 - Injection, methylprednisolone acetate, 20 mg 20 MG 4.987 - - - - - -
J1030 - Injection, methylprednisolone acetate, 40 mg 40 MG 5.472 - - - - - -
J1040 - Injection, methylprednisolone acetate, 80 mg 80 MG 10.268 - - - - - -
J1050 - Injection, medroxyprogesterone acetate, 1 mg 1 MG 0.44 - - - - - -
J1071 - Injection, testosterone cypionate, 1 mg 1 MG 0.023 - - - - - -
J1100 - Injection, dexamethasone sodium phosphate, 1 mg 1 MG 0.117 - - - - - -
J1110 - Injection, dihydroergotamine mesylate, per 1 mg 1 MG 135.577 - - - - - -
J1120 - Injection, acetazolamide sodium, up to 500 mg 500 MG 19.692 - - - - - -
J1160 - Injection, digoxin, up to 0.5 mg 0.5 MG 8.339 - - - - - -
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 3039.529 - - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.572 - - - - - -
J1170 - Injection, hydromorphone, up to 4 mg 4 MG 2.099 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 196.898 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.615 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 84.515 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 497.797 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 18.913 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 7.551 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 0.801 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 5.469 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.447 - - - - - -
J1267 - Injection, doripenem, 10 mg 10 MG 0.723 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.732 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 419.748 - - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 223.2 - - - - - -
* 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