• Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 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.
Page 1 * Effective January 1, 2018 through March 31, 2018
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 0.222 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.711 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.073 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.987 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.934 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.087 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.377 - - - - - -
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 48.549 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1206.831 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.219 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.068 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.69 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.596 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 971.945 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 171.407 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1812.765 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 974.038 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 159.755 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.54 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.675 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.478 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 7.202 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 32.987 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 14.92 - - - - - -
* Effective January 1, 2018 through March 31, 2018

Drugs not otherwise classified - January 2018

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2018 through March 31, 2018

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.094
Allopurinol Sodium 500 MG 3727.4
Aminocaproic acid 250 MG 0.27
Aztreonam 500 MG 13.179
Bumetanide 0.25 MG 0.265
Bupivacaine 1 ML 0.081
Clevidipine Butyrate 1 MG 2.653
Clindamycin Phosphate 150 MG 1.087
Coagulation Factor IX, Recombinant (Ixinity) I IU 1.455
Diltiazem Hydrochloride 5 MG 0.205
Doxycycline Hyclate 100 MG 17.778
Esmolol Hydrochloride 10 MG 1.458
Famotidine 10 MG 0.409
Flumazenil 0.1 MG 0.543
Folic Acid 5 MG 2.14
Glucarpidase 10 UNITS 298.281
Glycopyrrolate injection 0.2 MG 6.108
Hexaminolevulinate HCl 100 mg, per study dose 1035.217
Labetalol Hcl 5 MG 0.365
Metoprolol Tartrate 1 MG 0.168
Metronidazole inj 500 MG 1.024
Nitroglycerin 5 MG 1.057
Olanzapine short acting intramuscular injection 0.5 MG 1.04
Paliperidone Palmitate (Invega Trinza) 1 MG 8.821
Rifampin 600 MG 103.846
Rituximab/Hyaluronidase (Rituxan Hycela) 100 MG (rituximab) 460.3739 Added January 2018
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.45
Sulfamethoxazole-Trimethoprim 400-80 MG 0.64
Vasopressin 20 UNITS 148.146

ASP Drug Pricing History