• Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2021 (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 Jul 1, 2021 through Sep 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 4.971 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.203 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 6.11 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 42.931 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 9.424 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 28.334 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.843 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.045 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.788 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.581 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 5.694 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.916 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.884 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.095 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 179.42 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 58.454 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4029.227 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.804 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 47.578 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 29.12 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 17.325 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 172.612 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 12.041 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 15.194 - - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.753 - - - - - -
* Effective Jul 1, 2021 through Sep 30, 2021

Drugs not otherwise classified - July 2021

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective Jul 1, 2021 through Sep 30, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.932
Allopurinol Sodium 500 MG 3320.364
Aminocaproic acid 250 MG 0.293
Aztreonam 500 MG 14.167
Bumetanide 0.25 MG 0.281
Bupivacaine 1 ML 0.089
Clindamycin Phosphate 150 MG 0.824
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.21 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.294
Doxycycline Hyclate 100 MG 19.079
Esmolol Hydrochloride 10 MG 0.312
Famotidine 10 MG 0.432
Flumazenil 0.1 MG 0.793
Folic Acid 5 MG 2.919
Glucarpidase 10 UNITS 345.308
Glycopyrrolate injection 0.2 MG 2.317
Immune Globulin (Cutaquig) 100 MG 13.394
Immune Globulin (Panzyga) 500 MG 62.968
Labetalol Hcl 5 MG 0.126
Metoprolol Tartrate 1 MG 0.141
Metronidazole inj 500 MG 1.138
Nitroglycerin 5 MG 1.28
Olanzapine short acting intramuscular injection 0.5 MG 1.282
Paliperidone Palmitate (Invega Trinza) 1 MG 10.524
Rabies Immune Globulin (Kedrab) 150 IU 243.784
Rifampin 600 MG 106.951
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.481
Sulfamethoxazole-Trimethoprim 400-80 MG 0.581
Vasopressin 20 UNITS 210.415

ASP (Average Sale Price) Drug Pricing History