• 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 2 * 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
J0285 - Injection, amphotericin b, 50 mg 50 MG 30.244 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 14.496 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 19.774 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 1.259 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 3.009 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.498 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 4.568 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 4.592 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.266 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.055 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 45.28 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 167.244 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 76.521 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3341.06 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.834 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 41.937 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 69.247 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 25.776 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 8.508 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 10.659 - - - - - -
J0570 - Buprenorphine implant, 74.2 mg 74.2 MG 1280.518 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 1.333 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 5.942 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 7.796 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 11.688 - - 95% 15.63 - -
* 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