ASP Drug Pricing - (2nd Quarter)
April 2021
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2020 (4th 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 4 * Effective April 1, 2021 - June 30, 2021
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.906 - - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 5.778 - - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 6.357 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.535 - - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 1.985 - - - - - -
J0698 - Injection, cefotaxime sodium, per gm 1 GM 2.332 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.092 - - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.356 - - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 2.005 - - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 92.45 - - - - - -
J0717 - Injection, certolizumab pegol, 1 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) 1 MG 8.076 - - - - - -
J0720 - Injection, chloramphenicol sodium succinate, up to 1 gm 1 GM 37.119 - - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 21.805 - - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 23.486 - - - - - -
J0740 - Injection, cidofovir, 375 mg 375 MG 623.278 - - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.251 - - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 7.532 - - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 0.989 - - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 16.367 - - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 54.436 - - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 5.064 - - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 122.434 - - - - - -
J0795 - Injection, corticorelin ovine triflutate, 1 microgram 1 MCG 9.673 - - - - - -
J0800 - Injection, corticotropin, up to 40 units 40 UNITS 3898.63 - - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 34.346 - - - - - -
* Effective April 1, 2021 - June 30, 2021

Drugs not otherwise classified - April 2021

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2021 - June 30, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.261
Allopurinol Sodium 500 MG 3203.906
Aminocaproic acid 250 MG 0.335
Aztreonam 500 MG 13.685
Bumetanide 0.25 MG 0.304
Bupivacaine 1 ML 0.087
Clindamycin Phosphate 150 MG 0.758
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.21 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.339
Doxycycline Hyclate 100 MG 19.508
Esmolol Hydrochloride 10 MG 0.271
Famotidine 10 MG 0.433
Flumazenil 0.1 MG 0.786
Folic Acid 5 MG 2.901
Glucarpidase 10 UNITS 345.176
Glycopyrrolate injection 0.2 MG 2.242
Immune Globulin (Cutaquig) 100 MG 16.437
Immune Globulin (Panzyga) 500 MG 62.292
Labetalol Hcl 5 MG 0.153
Metoprolol Tartrate 1 MG 0.145
Metronidazole inj 500 MG 1.194
Nitroglycerin 5 MG 1.282
Olanzapine short acting intramuscular injection 0.5 MG 1.248
Paliperidone Palmitate (Invega Trinza) 1 MG 10.19
Rabies Immune Globulin (Kedrab) 150 IU 258.074
Rifampin 600 MG 106.173
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.513
Sulfamethoxazole-Trimethoprim 400-80 MG 0.582
Vasopressin 20 UNITS 204.544

ASP (Average Sale Price) Drug Pricing History