• Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2017 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 July 1, 2017 through September 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 0.233 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.751 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.083 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 2.054 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.864 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 13.943 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.378 - - - - - -
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 47.613 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1235.467 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.26 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.076 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.588 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.295 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 978.39 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 170.989 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1781.985 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 1034.125 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 159.737 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.943 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.632 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.803 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 6.694 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 32.585 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 13.081 - - - - - -
* Effective July 1, 2017 through September 30, 2017

Drugs not otherwise classified

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

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.187
Allopurinol Sodium 500 MG 3850.194
Aminocaproic acid 250 MG 0.274
Atezolizumab (Tecentriq) 10 MG 75.602
Aztreonam 500 MG 12.857
Bumetanide 0.25 MG 0.228
Bupivacaine 1 ML 0.079
Clevidipine Butyrate 1 MG 2.186
Clindamycin Phosphate 150 MG 0.988
Coagulation Factor IX (Recombinant) (Ixinity) I IU 1.453
Diltiazem Hydrochloride 5 MG 0.216
Doxycycline Hyclate 100 MG 18.581
Esmolol Hydrochloride 10 MG 1.125
Famotidine 10 MG 0.397
Flumazenil 0.1 MG 0.504
Folic Acid 5 MG 2.518
Glucarpidase 10 UNITS 284.081
Glycopyrrolate injection 0.2 MG 6.427
Granisetron extended release (Sustol) 0.1 MG 5.154
Hexaminolevulinate HCl 100 mg, per study dose 1033.5
Labetalol Hcl 5 MG 0.337
Metoprolol Tartrate 1 MG 0.176
Metronidazole inj 500 MG 1.122
Nitroglycerin 5 MG 0.995
Olanzapine short acting intramuscular injection 0.5 MG 1.104
Olaratumab (Lartruvo) 10 MG 49.95 Added July 2017
Paliperidone Palmitate (Invega Trinza) 1 MG 8.508
Rifampin 600 MG 111.077
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.484
Sulfamethoxazole-Trimethoprim 400-80 MG 0.729
Vasopressin 20 UNITS 136.332

ASP Drug Pricing History