• Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2018 (1st 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 July 1, 2018 through September 30, 2018
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 48.06676 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 1.116 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.391 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.562 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 2.843 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.237 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.049 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.066 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 50.444 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 173.31 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 59.392 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3656.007 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.829 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 43.619 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 77.12 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 16.677 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 10.925 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 13.937 - - - - - -
J0570 - Buprenorphine implant, 74.2 mg 74.2 MG 1250.924 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 0.962 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 6.158 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.425 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 12.015 - - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.082 - - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 3.915 - - - - - -
* Effective July 1, 2018 through September 30, 2018

Drugs not otherwise classified - July 2018

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

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.556
Allopurinol Sodium 500 MG 3594.588
Aminocaproic acid 250 MG 0.285
Aztreonam 500 MG 12.96
Bumetanide 0.25 MG 0.269
Bupivacaine 1 ML 0.106
Clindamycin Phosphate 150 MG 1.084
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.436 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.203
Doxycycline Hyclate 100 MG 18.491
Esmolol Hydrochloride 10 MG 1.619
Famotidine 10 MG 0.415
Flumazenil 0.1 MG 0.729
Folic Acid 5 MG 2.679
Glucarpidase 10 UNITS 298.716
Glycopyrrolate injection 0.2 MG 5.721
Hexaminolevulinate HCl 100 mg, per study dose 1086.5
Labetalol Hcl 5 MG 0.244
Metoprolol Tartrate 1 MG 0.172
Metronidazole inj 500 MG 1.206
Nitroglycerin 5 MG 1.172
Olanzapine short acting intramuscular injection 0.5 MG 1.287
Paliperidone Palmitate (Invega Trinza) 1 MG 9.266
Puraply AM 1 SQ CM 72.608
Rifampin 600 MG 101.188
Rituximab/Hyaluronidase (Rituxan Hycela) 100 MG (rituximab) 463.782
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.665
Sulfamethoxazole-Trimethoprim 400-80 MG 0.607
Vasopressin 20 UNITS 150.174

ASP (Average Sale Price) Drug Pricing History