• 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.
Page 1 * Effective January 1, 2017 through March 31, 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 0.204 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.626 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.074 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 2.026 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.818 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.018 - - - - - -
A9583 - Injection, gadofosveset trisodium, 1 ml 1 ML 18.112 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.385 - - - - - -
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 45.88 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1147.524 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.533 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.075 - - - - - -
J0135 - Injection, adalimumab, 20 mg 20 MG 909.215 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.601 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.336 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 980.381 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 164.796 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1750.714 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 412.27 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 159.732 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.851 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.367 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.766 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 9.044 - - - - - -
* Effective January 1, 2017 through March 31, 2017

Drugs not otherwise classified - January 2017

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

Drug name Dosage Payment limit Notes
Bumetanide 0.25 MG 0.258
Bupivacaine 1 ML 0.086
Clevidipine Butyrate 1 MG 3.041
Clindamycin Phosphate 150 MG 0.992
Coagulation Factor IX (Recombinant) (Ixinity) I IU 1.41
Diltiazem Hydrochloride 5 MG 0.196
Doxycycline Hyclate 100 MG 18.02
Esmolol Hydrochloride 10 MG 1.027
Famotidine 10 MG 0.38
Flumazenil 0.1 MG 0.752
Folic Acid 5 MG 2.733
Glucarpidase 10 UNITS 284.081
Glycopyrrolate injection 0.2 MG 6.369
Hexaminolevulinate HCl 100 mg, per study dose 959.067
Integra Meshed Bilayer Wound Matrix 1 SQ CM 55.731
Labetalol Hcl 5 MG 0.161
Metoprolol Tartrate 1 MG 0.155
Metronidazole inj 500 MG 1.125
Nitroglycerin 5 MG 0.947
Olanzapine short acting intramuscular injection 0.5 MG 1.225
Paliperidone Palmitate (Invega Trinza) 1 MG 8.137
Rifampin 600 MG 122.599
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.436
Sulfamethoxazole-Trimethoprim 400-80 MG 0.76
Vasopressin 20 UNITS 129.581

ASP Drug Pricing History