• Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2020 (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, 2020 through December 31, 2020
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 0.175 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.502 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.814 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.75 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.527 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.762 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.357 - - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1173.505 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 3.147 - - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.018 - - - - - -
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 58.103 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 1.056 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.053 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.568 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.884 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 928.241 - - - - - -
J0179 - Injection, brolucizumab-dbll, 1 mg 1 MG 311.994 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 188.99 - - - - - -
J0185 - Injection, aprepitant, 1 mg 1 MG 1.732 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 1984.32 - - - - - -
J0207 - Injection, amifostine, 500 mg 500 MG 1135.69106666667 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 174.488 - - - - - -
J0222 - Injection, patisiran, 0.1 mg 0.1 MG 97.843 - - - - - -
J0223 - Injection, givosiran, 0.5 mg 0.5 MG 106.875 - - - - - -
* Effective October 1, 2020 through December 31, 2020

Drugs not otherwise classified - October 2020

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2020 through December 31, 2020

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.656
Allopurinol Sodium 500 MG 2981.884
Aminocaproic acid 250 MG 0.345
Aztreonam 500 MG 12.511
Bumetanide 0.25 MG 0.287
Bupivacaine 1 ML 0.068
Clindamycin Phosphate 150 MG 0.782
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.691 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.331
Doxycycline Hyclate 100 MG 17.7
Esmolol Hydrochloride 10 MG 0.313
Famotidine 10 MG 0.417
Flumazenil 0.1 MG 0.717
Folic Acid 5 MG 2.77
Glucarpidase 10 UNITS 328.863
Glycopyrrolate injection 0.2 MG 2.574
Immune Globulin (Asceniv) 500 MG 481.77
Immune Globulin (Cutaquig) 100 MG 16.798
Immune Globulin (Panzyga) 500 MG 66.268
Labetalol Hcl 5 MG 0.195
Metoprolol Tartrate 1 MG 0.138
Metronidazole inj 500 MG 1.269
Nitroglycerin 5 MG 1.225
Olanzapine short acting intramuscular injection 0.5 MG 1.29
Paliperidone Palmitate (Invega Trinza) 1 MG 10.206
Rabies Immune Globulin (Kedrab) 150 IU 222.577
Rifampin 600 MG 103.592
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.327
Sulfamethoxazole-Trimethoprim 400-80 MG 0.665
Vasopressin 20 UNITS 201.585

ASP (Average Sale Price) Drug Pricing History