• Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2018 (3rd 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 1 * Effective January 1, 2019 through March 31, 2019
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 0.213 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.496 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.014 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.94 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.745 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.749 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.389 - - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1088.196 - - - - - -
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 51.614 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1429.0708 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.446 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.048 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.731 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.739 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 963.537 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 178.166 - - - - - -
J0185 - Injection, aprepitant, 1 mg 1 MG 2.109 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1882.06 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 979.745 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 166.2 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.55 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.696 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.177 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 7.018 - - - - - -
* Effective January 1, 2019 through March 31, 2019

Drugs not otherwise classified - January 2019

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2019 through March 31, 2019

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.383
Allopurinol Sodium 500 MG 3265.658
Aminocaproic acid 250 MG 0.312
Aripiprazole lauroxil (Aristada Initio) 1 MG 2.93590162962963 Added January 2019
Aztreonam 500 MG 12.756
Bumetanide 0.25 MG 0.265
Bupivacaine 1 ML 0.124
Clindamycin Phosphate 150 MG 1.011
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.43 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.254
Doxycycline Hyclate 100 MG 19.025
Esmolol Hydrochloride 10 MG 0.796
Famotidine 10 MG 0.427
Flumazenil 0.1 MG 1.257
Folic Acid 5 MG 2.879
Glucarpidase 10 UNITS 313.198
Glycopyrrolate injection 0.2 MG 4.102
Labetalol Hcl 5 MG 0.181
Metoprolol Tartrate 1 MG 0.166
Metronidazole inj 500 MG 1.276
Nitroglycerin 5 MG 1.2
Olanzapine short acting intramuscular injection 0.5 MG 1.112
Paliperidone Palmitate (Invega Trinza) 1 MG 9.248
Rifampin 600 MG 107.442
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.575
Sulfamethoxazole-Trimethoprim 400-80 MG 0.588
Vasopressin 20 UNITS 164.37

ASP (Average Sale Price) Drug Pricing History