• Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2019 (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 2 * Effective October 1, 2019 through December 31, 2019
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 40.28 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 6.184 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 26.087 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.999 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.063 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.55 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 4.213 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.704 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 3.049 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.065 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 55.289 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 169.513 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 50.046 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3799.932 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.776 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 44.824 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 57.583 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 17.739 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 168.502 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 10.887 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 13.82 - - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.829 - - - - - -
J0570 - Buprenorphine implant, 74.2 mg 74.2 MG 1303.529 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 0.619 - - - - - -
J0584 - Injection, burosumab-twza 1 mg 1 MG 353.21 - - - - - -
* Effective October 1, 2019 through December 31, 2019

Drugs not otherwise classified - October 2019

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2019 through December 31, 2019

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 0.875
Allopurinol Sodium 500 MG 2530.659
Aminocaproic acid 250 MG 0.306
Aztreonam 500 MG 12.687
Bumetanide 0.25 MG 0.313
Bupivacaine 1 ML 0.127
Clindamycin Phosphate 150 MG 0.869
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.49227811651336 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.313
Doxycycline Hyclate 100 MG 19.045
Esmolol Hydrochloride 10 MG 0.345
Famotidine 10 MG 0.409
Flumazenil 0.1 MG 0.754
Folic Acid 5 MG 2.698
Glucarpidase 10 UNITS 328.863
Glycopyrrolate injection 0.2 MG 3.077
Labetalol Hcl 5 MG 0.21
Metoprolol Tartrate 1 MG 0.197
Metronidazole inj 500 MG 1.254
Nitroglycerin 5 MG 1.185
Olanzapine short acting intramuscular injection 0.5 MG 1.146
Paliperidone Palmitate (Invega Trinza) 1 MG 9.793
Rifampin 600 MG 105.005
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.345
Sulfamethoxazole-Trimethoprim 400-80 MG 0.588
Vasopressin 20 UNITS 165.466

ASP (Average Sale Price) Drug Pricing History