• Note 1: Payment allowance limits subject to the ASP methodology are based on 4Q15 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 April 1, 2016 through June 30, 2016
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 0.207 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.644 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.09 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 2.02 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.853 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 13.972 - - - - - -
A9583 - Injection, gadofosveset trisodium, 1 ml 1 ML 15.189 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.391 - - - - - -
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 41.05 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1082.62 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.631 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.083 - - - - - -
J0135 - Injection, adalimumab, 20 mg 20 MG 796.671 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.77 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.128 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 980.5 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 159.658 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1738.686 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 390.336 - - - - - -
J0220 - Injection, alglucosidase alfa, 10 mg, not otherwise specified 10 MG 206.7 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 154.616 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.595 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.272 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.636 - - - - - -
* Effective April 1, 2016 through June 30, 2016

Drugs not otherwise classified

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2016 through June 30, 2016

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.018
Allopurinol Sodium 500 MG 1876.507
Aminocaproic acid 250 MG 0.25
Aztreonam 500 MG 11.487
Bumetanide 0.25 MG 0.267
Bupivacaine 1 ML 0.081
Clevidipine Butyrate 1 MG 2.365
Clindamycin Phosphate 150 MG 1.006
Diltiazem Hydrochloride 5 MG 0.199
Doxycycline Hyclate 100 MG 13.265
Esmolol Hydrochloride 10 MG 0.876
Esomeprazole Sodium 20 MG 12.564
Famotidine 10 MG 0.399
Flumazenil 0.1 MG 0.791
Folic Acid 5 MG 2.471
Glucarpidase 10 UNITS 270.724
Glycopyrrolate 0.2 MG 6.639
Hexaminolevulinate HCl 100 mg, per study dose 954
Integra Meshed Bilayer Wound Matrix 1 SQ CM 44.073
Invega Trinza 1 MG 7.562
Ixinity I IU 1.461
Labetalol Hcl 5 MG 0.343
Metoprolol Tartrate 1 MG 0.179
Metronidazole inj 500 MG 1.154
Nitroglycerin 5 MG 1.07
Olanzapine short acting intramuscular injection 0.5 MG 1.308
Rifampin 600 MG 136.586
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.432
Sulfamethoxazole-Trimethoprim 400-80 MG 0.702
Vasopressin 20 UNITS 95.035

ASP Drug Pricing History