• Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2020 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
Page 2 * Effective January 1, 2021 through March 31, 2021
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.523 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.887 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.064 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 10.335 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 38.905 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 9.373 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 27.239 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.886 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.072 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.461 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.543 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 2.941 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.703 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.301 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.08 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 172.78 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 56.663 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4019.07 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.792 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 46.835 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 34.635 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 17.161 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 171.3 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 12.008 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 15.104 - - - - - -
* Effective January 1, 2021 through March 31, 2021

Drugs not otherwise classified - January 2021

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2021 through March 31, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.917
Allopurinol Sodium 500 MG 3149.724
Aminocaproic acid 250 MG 0.341
Aztreonam 500 MG 12.574
Bumetanide 0.25 MG 0.354
Bupivacaine 1 ML 0.064
Clindamycin Phosphate 150 MG 0.89
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.737 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.331
Doxycycline Hyclate 100 MG 18.736
Esmolol Hydrochloride 10 MG 0.33
Famotidine 10 MG 0.389
Flumazenil 0.1 MG 0.683
Folic Acid 5 MG 2.638
Glucarpidase 10 UNITS 328.863
Glycopyrrolate injection 0.2 MG 2.399
Immune Globulin (Asceniv) 500 MG 481.77
Immune Globulin (Cutaquig) 100 MG 18.184
Immune Globulin (Panzyga) 500 MG 64.513
Labetalol Hcl 5 MG 0.151
Metoprolol Tartrate 1 MG 0.123
Metronidazole inj 500 MG 1.221
Nitroglycerin 5 MG 1.255
Olanzapine short acting intramuscular injection 0.5 MG 1.263
Paliperidone Palmitate (Invega Trinza) 1 MG 10.195
Rabies Immune Globulin (Kedrab) 150 IU 231.649
Rifampin 600 MG 104.387
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.464
Sulfamethoxazole-Trimethoprim 400-80 MG 0.627
Vasopressin 20 UNITS 203.34

ASP (Average Sale Price) Drug Pricing History