• Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2018 (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 3 * Effective April 1, 2019 through June 30, 2019
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.407 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 11.973 - - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.086 - - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 4.218 - - - - - -
J0594 - injection, busulfan, 1 mg 1 MG 6.821 - - - - - -
J0595 - Injection, butorphanol tartrate, 1 mg 1 MG 2.508 - - - - - -
J0596 - Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units 10 UNITS 27.342 - - - - - -
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 48.944 - - - - - -
J0598 - Injection, c-1 esterase inhibitor (human), cinryze, 10 units 10 UNITS 54.966 - - - - - -
J0600 - Injection, edetate calcium disodium, up to 1000 mg 1000 MG 5594.422 - - - - - -
J0610 - Injection, calcium gluconate, per 10 ml 10 ML 3.216 - - - - - -
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 2657.542 - - - - - -
J0636 - Injection, calcitriol, 0.1 mcg 0.1 MCG 0.524 - - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 10.44 - - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 111.015 - - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 3.315 - - - - - -
J0641 - Injection, levoleucovorin, not otherwise specified, 0.5 mg 0.5 MG 0.225 - - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 1.759 - - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.905 - - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.83 - - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 4.501 - - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 5.412 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.625 - - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 2.144 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.807 - - - - - -
* Effective April 1, 2019 through June 30, 2019

Drugs not otherwise classified - April 2019

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2019 through June 30, 2019

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.485
Allopurinol Sodium 500 MG 2920.343
Aminocaproic acid 250 MG 0.307
Aripiprazole lauroxil (Aristada Initio) 1 MG 2.71
Aztreonam 500 MG 13.074
Bendamustine Hcl (Eagle) 1 MG 23.663 Added April 2019
Bumetanide 0.25 MG 0.293
Bupivacaine 1 ML 0.095
Clindamycin Phosphate 150 MG 0.908
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.406 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.278
Doxycycline Hyclate 100 MG 18.405
Esmolol Hydrochloride 10 MG 0.717
Famotidine 10 MG 0.388
Flumazenil 0.1 MG 0.973
Folic Acid 5 MG 2.296
Glucarpidase 10 UNITS 313.198
Glycopyrrolate injection 0.2 MG 3.853
Labetalol Hcl 5 MG 0.177
Metoprolol Tartrate 1 MG 0.188
Metronidazole inj 500 MG 1.172
Nitroglycerin 5 MG 1.138
Olanzapine short acting intramuscular injection 0.5 MG 1.114
Paliperidone Palmitate (Invega Trinza) 1 MG 9.185
Rifampin 600 MG 91.923
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.396
Sulfamethoxazole-Trimethoprim 400-80 MG 0.571
Vasopressin 20 UNITS 165.121

ASP (Average Sale Price) Drug Pricing History