• Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2017 (4th 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 April 1, 2018 through June 30, 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 0.22 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.65 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.042 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.973 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 2.042 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.859 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.382 - - - - - -
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 50.164 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1204.494 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.161 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.061 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.728 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.578 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 968.794 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 172.189 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1817.56 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 948.179 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 160.637 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.446 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.643 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.351 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 7.722 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 33.836 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 17.352 - - - - - -
* Effective April 1, 2018 through June 30, 2018

Drugs not otherwise classified - April 2018

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2018 through June 30, 2018

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.46
Allopurinol Sodium 500 MG 3672.657
Aminocaproic acid 250 MG 0.278
Aztreonam 500 MG 13.032
Bumetanide 0.25 MG 0.256
Bupivacaine 1 ML 0.081
Clevidipine Butyrate 1 MG 2.745
Clindamycin Phosphate 150 MG 1.055
Coagulation Factor IX, Recombinant (Ixinity) I IU 1.469
Diltiazem Hydrochloride 5 MG 0.215
Doxycycline Hyclate 100 MG 17.888
Esmolol Hydrochloride 10 MG 1.525
Famotidine 10 MG 0.402
Flumazenil 0.1 MG 0.603
Folic Acid 5 MG 2.637
Glucarpidase 10 UNITS 298.281
Glycopyrrolate injection 0.2 MG 5.718
Hexaminolevulinate HCl 100 mg, per study dose 1086.5
Labetalol Hcl 5 MG 0.241
Metoprolol Tartrate 1 MG 0.2
Metronidazole inj 500 MG 1.216
Nitroglycerin 5 MG 1.123
Olanzapine short acting intramuscular injection 0.5 MG 0.98
Paliperidone Palmitate (Invega Trinza) 1 MG 8.832
Puraply AM 1 SQ CM 111.67 Added April 2018
Rifampin 600 MG 102.968
Rituximab/Hyaluronidase (Rituxan Hycela) 100 MG (rituximab) 457.208
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.647
Sulfamethoxazole-Trimethoprim 400-80 MG 0.675
Vasopressin 20 UNITS 150.365

ASP Drug Pricing History