• Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2018 (2nd 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 1 * Effective October 1, 2018 through December 31, 2018
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 0.207 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.568 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 2.035 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.964 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.719 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.829 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.412 - - - - - -
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 52.929 - - - - - -
J0130 - Injection abciximab, 10 mg 10 MG 1299.262 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.066 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.033 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.828 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.744 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 967.327 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 175.621 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1842.129 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 973.411 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 163.83 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.46 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.653 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.122 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 3.71212 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 32.377 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 17.723 - - - - - -
* Effective October 1, 2018 through December 31, 2018

Drugs not otherwise classified - October 2018

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2018 through December 31, 2018

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.555
Allopurinol Sodium 500 MG 3491.292
Aminocaproic acid 250 MG 0.281
Aprepitant (Cinvanti) 1 MG 2.104 Added October 2018
Aztreonam 500 MG 12.734
Benralizumab (Fasenra) 1 MG 167.471 Added October 2018
Bumetanide 0.25 MG 0.277
Bupivacaine 1 ML 0.098
Clindamycin Phosphate 150 MG 1.012
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.449 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.246
Doxycycline Hyclate 100 MG 18.735
Esmolol Hydrochloride 10 MG 0.609
Famotidine 10 MG 0.386
Flumazenil 0.1 MG 0.635
Folic Acid 5 MG 2.691
Glucarpidase 10 UNITS 313.31
Glycopyrrolate injection 0.2 MG 4.419
Hexaminolevulinate HCl 100 mg, per study dose 1086.5
Labetalol Hcl 5 MG 0.162
Metoprolol Tartrate 1 MG 0.171
Metronidazole inj 500 MG 1.173
Nitroglycerin 5 MG 1.087
Olanzapine short acting intramuscular injection 0.5 MG 1.238
Paliperidone Palmitate (Invega Trinza) 1 MG 9.242
Puraply AM 1 SQ CM 68.96
Rifampin 600 MG 105.014
Rituximab/Hyaluronidase (Rituxan Hycela) 100 MG (rituximab) 457.222
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.713
Sulfamethoxazole-Trimethoprim 400-80 MG 0.626
Vasopressin 20 UNITS 150.099

ASP (Average Sale Price) Drug Pricing History