• Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2020 (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 2 * Effective April 1, 2021 - June 30, 2021
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.865 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.199 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 9.501 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 39.917 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 9.37 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 27.067 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.896 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.18 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.753 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.542 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 4.867 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.704 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 4.579 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.093 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 179.013 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 57.061 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4016.82 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.788 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 46.874 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 33.847 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 17.413 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 169.054 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 12.057 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 15.228 - - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.659 - - - - - -
* Effective April 1, 2021 - June 30, 2021

Drugs not otherwise classified - April 2021

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2021 - June 30, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.261
Allopurinol Sodium 500 MG 3203.906
Aminocaproic acid 250 MG 0.335
Aztreonam 500 MG 13.685
Bumetanide 0.25 MG 0.304
Bupivacaine 1 ML 0.087
Clindamycin Phosphate 150 MG 0.758
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.21 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.339
Doxycycline Hyclate 100 MG 19.508
Esmolol Hydrochloride 10 MG 0.271
Famotidine 10 MG 0.433
Flumazenil 0.1 MG 0.786
Folic Acid 5 MG 2.901
Glucarpidase 10 UNITS 345.176
Glycopyrrolate injection 0.2 MG 2.242
Immune Globulin (Cutaquig) 100 MG 16.437
Immune Globulin (Panzyga) 500 MG 62.292
Labetalol Hcl 5 MG 0.153
Metoprolol Tartrate 1 MG 0.145
Metronidazole inj 500 MG 1.194
Nitroglycerin 5 MG 1.282
Olanzapine short acting intramuscular injection 0.5 MG 1.248
Paliperidone Palmitate (Invega Trinza) 1 MG 10.19
Rabies Immune Globulin (Kedrab) 150 IU 258.074
Rifampin 600 MG 106.173
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.513
Sulfamethoxazole-Trimethoprim 400-80 MG 0.582
Vasopressin 20 UNITS 204.544

ASP (Average Sale Price) Drug Pricing History