• Note 1: Payment allowance limits subject to the ASP methodology are based on 3Q15 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 1 * Effective January 1, 2016 through March 31, 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 2.133 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 2.012 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.89 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 13.999 - - - - - -
A9583 - Injection, gadofosveset trisodium, 1 ml 1 ML 14.818 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.393 - - - - - -
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 39.442 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1015.544 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.719 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.075 - - - - - -
J0135 - Injection, adalimumab, 20 mg 20 MG 753.258 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.962 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.127 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 980.5 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 158.477 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1743.815 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 377.883 - - - - - -
J0220 - Injection, alglucosidase alfa, 10 mg, not otherwise specified 10 MG 206.7 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 153.598 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.593 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.272 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.155 - - - - - -
* Effective January 1, 2016 through March 31, 2016

Drugs not otherwise classified - January 2016

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2016 through March 31, 2016

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 0.913
Allopurinol Sodium 500 MG 1106.947
Aminocaproic acid 250 MG 0.253
Aztreonam 500 MG 15.571
Bumetanide 0.25 MG 0.284
Bupivacaine 1 ML 0.083
Clavulanate Potassium/Ticarcillin Disodium 0.1-3 GM 14.09482
Clevidipine Butyrate 1 MG 2.82
Clindamycin Phosphate 150 MG 1.057
Diltiazem Hydrochloride 5 MG 0.204
Doxycycline Hyclate 100 MG 14.004
Esmolol Hydrochloride 10 MG 0.838
Esomeprazole Sodium 20 MG 12.991
Famotidine 10 MG 0.405
Flumazenil 0.1 MG 0.635
Folic Acid 5 MG 2.583
Glucarpidase 10 UNITS 270.555
Glycopyrrolate 0.2 MG 6.627
Hexaminolevulinate HCl 100 mg, per study dose 883.828
Integra Meshed Bilayer Wound Matrix 1 SQ CM 40.25
Invega Trinza 1 MG 7.595 Added January 2016
Ixinity I IU 1.46733649183147 Added January 2016
Labetalol Hcl 5 MG 0.19
Metoprolol Tartrate 1 MG 0.155
Metronidazole inj 500 MG 1.148
Nitroglycerin 5 MG 0.767
Olanzapine short acting intramuscular injection 0.5 MG 1.305
Rifampin 600 MG 141.319
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.332
Sulfamethoxazole-Trimethoprim 400-80 MG 0.506
SurgiMend 0.5 SQ CM 12.426
Vasopressin 20 UNITS 94.666

ASP (Average Sale Price) Drug Pricing History