• Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2019 (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, 2020 through June 30, 2020
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 0.178 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.415 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.886 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.858 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.554 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.743 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.375 - - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1173.378 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 3.306 - - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.018 - - - - - -
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 55.083 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.111 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.072 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.621 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.84 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 938.443 - - - - - -
J0179 - Injection, brolucizumab-dbll, 1 mg 1 MG 317.583 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 183.778 - - - - - -
J0185 - Injection, aprepitant, 1 mg 1 MG 2.011 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1949.596 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 980.143 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 171.213 - - - - - -
J0222 - Injection, patisiran, 0.1 mg 0.1 MG 98.209 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.434 - - - - - -
* Effective April 1, 2020 through June 30, 2020

Drugs not otherwise classified - April 2020

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2020 through June 30, 2020

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.507
Allopurinol Sodium 500 MG 2769.89
Aminocaproic acid 250 MG 0.291
Aztreonam 500 MG 12.807
Bumetanide 0.25 MG 0.297
Bupivacaine 1 ML 0.094
Clindamycin Phosphate 150 MG 0.904
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.62 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.371
Doxycycline Hyclate 100 MG 18.782
Esmolol Hydrochloride 10 MG 0.319
Famotidine 10 MG 0.403
Flumazenil 0.1 MG 0.647
Folic Acid 5 MG 2.771
Givosiran (Givlaari) 0.5 MG 106.269841269841 Added April 2020
Glucarpidase 10 UNITS 328.863
Glycopyrrolate injection 0.2 MG 2.778
Immune Globulin (Asceniv) 500 MG 468.135 Added April 2020
Immune Globulin (Cutaquig) 100 MG 17.445
Immune Globulin (Panzyga) 500 MG 70.049
Immune Globulin (Xemblify) 100 MG 17.613 Added April 2020
Labetalol Hcl 5 MG 0.394
Metoprolol Tartrate 1 MG 0.168
Metronidazole inj 500 MG 1.229
Nitroglycerin 5 MG 1.216
Olanzapine short acting intramuscular injection 0.5 MG 1.323
Paliperidone Palmitate (Invega Trinza) 1 MG 9.753
Pegfilgrastim-bmez (Ziextenzo)? 0.5 MG 336.941325
Rabies Immune Globulin (Kedrab) 150 IU 291.95
Rifampin 600 MG 110.463
Rituximab-pvvr (Ruxience) 10 MG 73.8304
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.265
Sulfamethoxazole-Trimethoprim 400-80 MG 0.586
Vasopressin 20 UNITS 179.848

ASP (Average Sale Price) Drug Pricing History