ASP Drug Pricing - (4th Quarter)
October 2017
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2017 (2nd Quarter) 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 2 * Effective October 1, 2017 through December 31, 2017
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 21.515 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 1.108 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.972 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.536 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 3.264 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 4.886 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.368 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.052 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 52.694 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 164.619 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 70.337 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3440.367 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.935 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 42.808 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 74.943 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 20.22 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 9.337 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 11.921 - - - - - -
J0570 - Buprenorphine implant, 74.2 mg 74.2 MG 1261.308 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 1.227 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 6.031 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.261 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 11.978 - - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.082 - - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 3.45 - - - - - -
* Effective October 1, 2017 through December 31, 2017

Drugs not otherwise classified - October 2017

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2017 through December 31, 2017

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.23
Allopurinol Sodium 500 MG 3748.108
Aminocaproic acid 250 MG 0.281
Atezolizumab (Tecentriq) 10 MG 75.643
Aztreonam 500 MG 12.764
Bumetanide 0.25 MG 0.264
Bupivacaine 1 ML 0.082
Clevidipine Butyrate 1 MG 2.434
Clindamycin Phosphate 150 MG 0.986
Coagulation Factor IX (Recombinant) (Ixinity) I IU 1.546
Diltiazem Hydrochloride 5 MG 0.195
Doxycycline Hyclate 100 MG 17.807
Esmolol Hydrochloride 10 MG 1.273
Famotidine 10 MG 0.4
Flumazenil 0.1 MG 0.641
Folic Acid 5 MG 2.576
Glucarpidase 10 UNITS 298.602
Glycopyrrolate injection 0.2 MG 6.165
Granisetron extended release (Sustol) 0.1 MG 4.883
Hexaminolevulinate HCl 100 mg, per study dose 1033.5
Labetalol Hcl 5 MG 0.429
Metoprolol Tartrate 1 MG 0.158
Metronidazole inj 500 MG 1.114
Nitroglycerin 5 MG 1.012
Olanzapine short acting intramuscular injection 0.5 MG 0.962
Olaratumab (Lartruvo) 10 MG 49.95
Paliperidone Palmitate (Invega Trinza) 1 MG 8.527
Rifampin 600 MG 102.882
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.178
Sulfamethoxazole-Trimethoprim 400-80 MG 0.662
Vasopressin 20 UNITS 136.258

ASP (Average Sale Price) Drug Pricing History