• Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q16 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 October 1, 2016 through December 31, 2016
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0285 - Injection, amphotericin b, 50 mg 50 MG 27.935 - - 95% 10.28 - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 13.407 - - 95% 21.85 - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 19.012 - - 95% 35.8 - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 1.307 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 3.697 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.507 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 4.591 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 4.383 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.307 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.036 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 39.337 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 173.425 - - 95% 215.18 - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 76.957 - - 95% 79.8 - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3196.111 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.841 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 42.018 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 63.589 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 34.42 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 7.964 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 10.307 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 1.529 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 5.93 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 7.902 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 11.708 - - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 4.907 - - - - - -
* Effective October 1, 2016 through December 31, 2016

Drugs not otherwise classified - October 2016

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2016 through December 31, 2016

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.356
Allopurinol Sodium 500 MG 3338.714
Aminocaproic acid 250 MG 0.257
Aztreonam 500 MG 12.226
Bumetanide 0.25 MG 0.265
Bupivacaine 1 ML 0.095
Clevidipine Butyrate 1 MG 2.887
Clindamycin Phosphate 150 MG 1.013
Darzalex 10 MG 46.846
Diltiazem Hydrochloride 5 MG 0.2
Doxycycline Hyclate 100 MG 17.564
Empliciti 1 MG 6.25
Esmolol Hydrochloride 10 MG 0.965
Famotidine 10 MG 0.364
Flumazenil 0.1 MG 0.871
Folic Acid 5 MG 2.463
Glucarpidase 10 UNITS 284.269
Glycopyrrolate 0.2 MG 6.457
Hexaminolevulinate HCl 100 mg, per study dose 954
Imlygic 1 million PFU 46.279 Added October 2016
Integra Meshed Bilayer Wound Matrix 1 SQ CM 50.138
Invega Trinza 1 MG 7.868
Ixinity I IU 1.481
Labetalol Hcl 5 MG 0.228
Metoprolol Tartrate 1 MG 0.164
Metronidazole inj 500 MG 1.151
Nitroglycerin 5 MG 0.95
Olanzapine short acting intramuscular injection 0.5 MG 1.205
Onivyde 1 MG 39.546
Portrazza 1 MG 5.276 Added October 2016
Probuphine System Kit 1 IMPLANT 1311.75 Added October 2016
Rifampin 600 MG 127.151
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.312
Sulfamethoxazole-Trimethoprim 400-80 MG 0.752
Tecentriq 10 MG 76.1433333333333 Added October 2016 - updated price
Vasopressin 20 UNITS 114.768
Yondelis 0.1 MG 283.338 Added October 2016

ASP Drug Pricing History