• Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2017 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 1 * Effective October 1, 2017 through December 31, 2017
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
A9575 - Injection, gadoterate meglumine, 0.1 ml 0.1 ml 0.224 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.729 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.08 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.992 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.985 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 13.938 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.378 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0129 - Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 10 MG 49.589 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1215.197 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.227 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.072 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.605 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.813 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 974.587 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 171.065 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1778.597 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 959.81 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 159.734 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.937 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.569 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.632 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 9.217 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 32.783 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 13.859 - - - - - -
* Effective October 1, 2017 through December 31, 2017

Drugs not otherwise classified - October 2017

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2017 through December 31, 2017

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.23
Allopurinol Sodium 500 MG 3748.108
Aminocaproic acid 250 MG 0.281
Atezolizumab (Tecentriq) 10 MG 75.643
Aztreonam 500 MG 12.764
Bumetanide 0.25 MG 0.264
Bupivacaine 1 ML 0.082
Clevidipine Butyrate 1 MG 2.434
Clindamycin Phosphate 150 MG 0.986
Coagulation Factor IX (Recombinant) (Ixinity) I IU 1.546
Diltiazem Hydrochloride 5 MG 0.195
Doxycycline Hyclate 100 MG 17.807
Esmolol Hydrochloride 10 MG 1.273
Famotidine 10 MG 0.4
Flumazenil 0.1 MG 0.641
Folic Acid 5 MG 2.576
Glucarpidase 10 UNITS 298.602
Glycopyrrolate injection 0.2 MG 6.165
Granisetron extended release (Sustol) 0.1 MG 4.883
Hexaminolevulinate HCl 100 mg, per study dose 1033.5
Labetalol Hcl 5 MG 0.429
Metoprolol Tartrate 1 MG 0.158
Metronidazole inj 500 MG 1.114
Nitroglycerin 5 MG 1.012
Olanzapine short acting intramuscular injection 0.5 MG 0.962
Olaratumab (Lartruvo) 10 MG 49.95
Paliperidone Palmitate (Invega Trinza) 1 MG 8.527
Rifampin 600 MG 102.882
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.178
Sulfamethoxazole-Trimethoprim 400-80 MG 0.662
Vasopressin 20 UNITS 136.258

ASP Drug Pricing History