• 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 1 * Effective April 1, 2017 through June 30, 2017
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 0.191 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.729 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.085 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.987 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.92 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 13.938 - - - - - -
A9583 - Injection, gadofosveset trisodium, 1 ml 1 ML 18.55795 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.38 - - - - - -
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 46.857 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1152.188 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.382 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.072 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.554 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.401 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 980.144 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 166.058 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1753.02 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 519.005 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 159.736 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.817 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.357 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.697 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 8.501 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 32.856 - - - - - -
* Effective April 1, 2017 through June 30, 2017

Drugs not otherwise classified

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2017 through June 30, 2017

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.469
Allopurinol Sodium 500 MG 3808.736
Aminocaproic acid 250 MG 0.257
Atezolizumab (Tecentriq) 10 MG 75.621
Aztreonam 500 MG 13.203
Bumetanide 0.25 MG 0.274
Bupivacaine 1 ML 0.083
Clevidipine Butyrate 1 MG 2.202
Clindamycin Phosphate 150 MG 1.072
Coagulation Factor IX (Recombinant) (Ixinity) I IU 1.394
Diltiazem Hydrochloride 5 MG 0.203
Doxycycline Hyclate 100 MG 18.714
Esmolol Hydrochloride 10 MG 1.139
Famotidine 10 MG 0.394
Flumazenil 0.1 MG 0.635
Folic Acid 5 MG 2.635
Glucarpidase 10 UNITS 284.215
Glycopyrrolate injection 0.2 MG 6.523
Granisetron extended release (Sustol) 0.1 MG 5.187 Added April 2017
Hexaminolevulinate HCl 100 mg, per study dose 1033.5
Labetalol Hcl 5 MG 0.216
Metoprolol Tartrate 1 MG 0.182
Metronidazole inj 500 MG 1.116
Nitroglycerin 5 MG 0.981
Olanzapine short acting intramuscular injection 0.5 MG 1.144
Paliperidone Palmitate (Invega Trinza) 1 MG 8.132
Rifampin 600 MG 111.547
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.337
Sulfamethoxazole-Trimethoprim 400-80 MG 0.714
Ustekinumab (Stelara IV infusion) 1 MG 12.781 Added April 2017
Vasopressin 20 UNITS 136.225

ASP Drug Pricing History