• Note 1: Payment allowance limits subject to the ASP methodology are based on 1Q16 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 July 1, 2016 through September 30, 2016
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 7.732 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 24.85 - - 95% 10.28 - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 13.134 - - 95% 21.85 - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 18.771 - - 95% 35.8 - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 1.591 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.691 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.529 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 5.035 - - - - - -
J0400 - Injection, aripiprazole, intramuscular, 0.25 mg 0.25 MG 0.756676923076923 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 4.396 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 4.343 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.044 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 41.53 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 178.025 - - 95% 215.18 - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 77.027 - - 95% 79.8 - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3180.214 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.843 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 42.087 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 63.507 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 24.728 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 7.435 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 9.519 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 1.896 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 5.837 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 7.71 - - - - - -
* Effective July 1, 2016 through September 30, 2016

Drugs not otherwise classified - July 2016

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective July 1, 2016 through September 30, 2016

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.205
Allopurinol Sodium 500 MG 2998.358
Aminocaproic acid 250 MG 0.258
Aztreonam 500 MG 12.397
Bumetanide 0.25 MG 0.266
Bupivacaine 1 ML 0.088
Clevidipine Butyrate 1 MG 2.521
Clindamycin Phosphate 150 MG 0.984
Darzalex 10 MG 46.43 Added July 2016
Diltiazem Hydrochloride 5 MG 0.211
Doxycycline Hyclate 100 MG 15.014
Empliciti 1 MG 6.254 Added July 2016
Esmolol Hydrochloride 10 MG 0.903
Esomeprazole Sodium 20 MG 2.233
Famotidine 10 MG 0.349
Flumazenil 0.1 MG 0.772
Folic Acid 5 MG 2.308
Glucarpidase 10 UNITS 270.683
Glycopyrrolate 0.2 MG 6.428
Hexaminolevulinate HCl 100 mg, per study dose 954
Integra Meshed Bilayer Wound Matrix 1 SQ CM 48.67
Invega Trinza 1 MG 7.844
Ixinity I IU 1.53972
Labetalol Hcl 5 MG 0.153
Metoprolol Tartrate 1 MG 0.16
Metronidazole inj 500 MG 1.14
Nitroglycerin 5 MG 1.023
Olanzapine short acting intramuscular injection 0.5 MG 1.255
Onivyde 1 MG 39.581 Added July 2016
Rifampin 600 MG 127.86
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.319
Sulfamethoxazole-Trimethoprim 400-80 MG 0.685
Vasopressin 20 UNITS 109.998

ASP Drug Pricing History