• Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2019 (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, 2019 through September 30, 2019
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.067 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 54.277 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 173.389 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 50.441 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3789.626 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.784 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 44.824 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 69.974 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 19.894 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 168.84 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 11.019 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 13.845 - - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.898 - - - - - -
J0570 - Buprenorphine implant, 74.2 mg 74.2 MG 1261.871 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 0.532 - - - - - -
J0584 - Injection, burosumab-twza 1 mg 1 MG 353.055 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 6.124 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.419 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 12.019 - - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.051 - - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 4.359 - - - - - -
J0594 - injection, busulfan, 1 mg 1 MG 5.778 - - - - - -
J0595 - Injection, butorphanol tartrate, 1 mg 1 MG 2.263 - - - - - -
J0596 - Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units 10 UNITS 27.817 - - - - - -
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 51.354 - - - - - -
* Effective July 1, 2019 through September 30, 2019

Drugs not otherwise classified - July 2019

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

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.015
Allopurinol Sodium 500 MG 2422.812
Aminocaproic acid 250 MG 0.308
Aripiprazole lauroxil (Aristada Initio) 1 MG 2.797
Aztreonam 500 MG 12.682
Bumetanide 0.25 MG 0.296
Bupivacaine 1 ML 0.137
Cemiplimab-rwlx (Libtayo) 1 MG 27.448 Added July 2019
Clindamycin Phosphate 150 MG 0.966
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.601 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.287
Doxycycline Hyclate 100 MG 17.138
Esmolol Hydrochloride 10 MG 0.454
Famotidine 10 MG 0.393
Flumazenil 0.1 MG 0.822
Folic Acid 5 MG 2.543
Glucarpidase 10 UNITS 313.198
Glycopyrrolate injection 0.2 MG 3.488
Labetalol Hcl 5 MG 0.216
Metoprolol Tartrate 1 MG 0.216
Metronidazole inj 500 MG 1.188
Mogamulizumab-kpkc (Poteligeo) 1 MG 200.87 Added July 2019
Nitroglycerin 5 MG 1.121
Olanzapine short acting intramuscular injection 0.5 MG 0.938
Paliperidone Palmitate (Invega Trinza) 1 MG 9.625
Rifampin 600 MG 108.859
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.374
Sulfamethoxazole-Trimethoprim 400-80 MG 0.579
Vasopressin 20 UNITS 165.339

ASP (Average Sale Price) Drug Pricing History