• Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2021 (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, 2021 through December 31, 2021
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.95 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.06 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 8.568 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 42.649 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 9.504 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 28.747 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.807 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.047 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.209 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.565 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 5.201 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 6.006 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 2.489 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.076 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 177.434 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 60.272 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4013.081 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.804 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 47.566 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 32.991 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 19.507 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 170.796 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 11.787 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 14.949 - - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.765 - - - - - -
* Effective October 1, 2021 through December 31, 2021

Drugs not otherwise classified - October 2021

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2021 through December 31, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.118
Allopurinol Sodium 500 MG 3212.092
Aminocaproic acid 250 MG 0.303
Aztreonam 500 MG 14.266
Bumetanide 0.25 MG 0.307
Bupivacaine 1 ML 0.09
Clindamycin Phosphate 150 MG 0.918
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.273 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.278
Doxycycline Hyclate 100 MG 18.396
Esmolol Hydrochloride 10 MG 0.324
Famotidine 10 MG 0.412
Flumazenil 0.1 MG 0.738
Folic Acid 5 MG 3.08
Glucarpidase 10 UNITS 345.308
Glycopyrrolate injection 0.2 MG 2.26
Immune Globulin (Cutaquig) 100 MG 13.324
Immune Globulin (Panzyga) 500 MG 63.582
Labetalol Hcl 5 MG 0.252
Metoprolol Tartrate 1 MG 0.15
Metronidazole inj 500 MG 1.235
Nitroglycerin 5 MG 1.367
Olanzapine short acting intramuscular injection 0.5 MG 1.323
Paliperidone Palmitate (Invega Trinza) 1 MG 10.693
Rifampin 600 MG 103.478
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.501
Sulfamethoxazole-Trimethoprim 400-80 MG 0.619
Vasopressin 20 UNITS 219.196

ASP (Average Sale Price) Drug Pricing History