• Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2020 (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, 2020 through September 30, 2020
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.377 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.812 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.386 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 7.31 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 39.016 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 9.307 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 26.54 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.928 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.075 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.755 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.507 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 2.878 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.699 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.42 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.064 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 175.16 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 55.784 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4016.591 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.766 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 46.168 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 40.652 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 15.515 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 171.896 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 11.678 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 15.033 - - - - - -
* Effective July 1, 2020 through September 30, 2020

Drugs not otherwise classified - July 2020

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

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.676
Allopurinol Sodium 500 MG 2812.246
Aminocaproic acid 250 MG 0.356
Aztreonam 500 MG 12.76
Bumetanide 0.25 MG 0.333
Bupivacaine 1 ML 0.075
Clindamycin Phosphate 150 MG 0.787
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.564 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.333
Doxycycline Hyclate 100 MG 18.678
Esmolol Hydrochloride 10 MG 0.384
Famotidine 10 MG 0.42
Flumazenil 0.1 MG 0.656
Folic Acid 5 MG 2.63
Glucarpidase 10 UNITS 328.863
Glycopyrrolate injection 0.2 MG 2.619
Immune Globulin (Asceniv) 500 MG 481.77
Immune Globulin (Cutaquig) 100 MG 19.486
Immune Globulin (Panzyga) 500 MG 67.999
Labetalol Hcl 5 MG 0.253
Metoprolol Tartrate 1 MG 0.179
Metronidazole inj 500 MG 1.263
Nitroglycerin 5 MG 1.233
Olanzapine short acting intramuscular injection 0.5 MG 1.244
Paliperidone Palmitate (Invega Trinza) 1 MG 10.108
Rabies Immune Globulin (Kedrab) 150 IU 271.401
Rifampin 600 MG 106.233
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.315
Sulfamethoxazole-Trimethoprim 400-80 MG 0.595
Vasopressin 20 UNITS 191.824

ASP (Average Sale Price) Drug Pricing History