• Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2021 (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, 2022 through March 31, 2022
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 4.546 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.982 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 0.912 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 6.139 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 41.002 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 9.602 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 29.467 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.711 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.099 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.727 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.567 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 5.353 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.99 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 2.634 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.088 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 181.568 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 73.059 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4037.651 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.789 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 48.233 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 30.394 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 19.02 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 167.44 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 11.776 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 15.044 - - - - - -
* Effective January 1, 2022 through March 31, 2022

Drugs not otherwise classified - January 2022

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2022 through March 31, 2022

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.973
Allopurinol Sodium 500 MG 3175.581
Aminocaproic acid 250 MG 0.303
Aztreonam 500 MG 14.07
Bumetanide 0.25 MG 0.289
Bupivacaine 1 ML 0.107
Clindamycin Phosphate 150 MG 1.054
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.274 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.287
Doxycycline Hyclate 100 MG 17.547
Esmolol Hydrochloride 10 MG 0.292
Famotidine 10 MG 0.434
Flumazenil 0.1 MG 0.894
Folic Acid 5 MG 2.522
Glucarpidase 10 UNITS 345.308
Glycopyrrolate injection 0.2 MG 2.072
Immune Globulin (Cutaquig) 100 MG 13.526
Immune Globulin (Panzyga) 500 MG 65.046
Labetalol Hcl 5 MG 0.16
Metoprolol Tartrate 1 MG 0.14
Metronidazole inj 500 MG 1.177
Nitroglycerin 5 MG 1.352
Olanzapine short acting intramuscular injection 0.5 MG 1.122
Paliperidone Palmitate (Invega Trinza) 1 MG 10.673
Rifampin 600 MG 98.068
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.497
Sulfamethoxazole-Trimethoprim 400-80 MG 0.603
Vasopressin 20 UNITS 219.428

ASP (Average Sale Price) Drug Pricing History