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Table III: 2019 Medicare Drug Fee Schedule* CY 2019 4Th Quarter

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Table III: 2019 Medicare Drug Fee Schedule* CY 2019 4Th Quarter Table III: 2019 Medicare Drug Fee Schedule* CY 2019 4th Quarter Average Sales Price (ASP) Data Plus 6 Percent *The Medicare payments allowance limits are effective Oct. 1 through Dec. 31, 2019. CY 2019 CY 2019 CY 2019 CY 2019 Effective Jan. 1 Effective Apr. 1 Effective July 1 Effective Oct. 1 Through Mar. 31 Through June 30 Throught Sept. 30 Through Dec. 31 Code Description Code Dosage ASP plus 6 percent ASP Plus 6 percent ASP Plus 6 percent ASP plus 6 percent J0129 Abatacept 10mg $51.61 $52.49 $53.94 $54.32 J0130 Abciximab injection 10mg $1,429.07 $1,429.07 $1,429.07 $1,429.07 J0133 Acyclovir, 5 mg 5mg $0.05 $0.05 $0.04 $0.04 J0171 Adrenalin epinephrin inject 0.1mg $0.74 $0.76 $0.86 $0.83 J0207 Amifostine 500mg $979.75 $990.39 $977.31 $1,003.59 J0256 Alpha 1 proteinase inhibitor 10mg $4.55 $4.56 $4.51 $4.55 J0280 Aminophyllin 250 MG inj 250mg $7.02 $7.33 $7.33 $10.88 J0289 Amphotericin b liposome inj 10mg $22.19 $23.92 $18.32 $26.09 J0295 Ampicillin sodium per 1.5 gm 1.5gm $2.62 $2.81 $3.32 $2.06 J0360 Hydralazine hcl injection 20mg $2.58 $2.58 $4.07 $4.21 J0456 Azithromycin 500mg $2.76 $2.58 $2.75 $3.05 J0461 Atropine sulfate injection 0.01mg $0.07 $0.07 $0.07 $0.06 J0475 Baclofen 10 MG injection 10mg $169.75 $174.19 $173.39 $169.51 J0476 Baclofen intrathecal trial 50mcg $44.35 $49.98 $50.44 $50.05 J0480 Basiliximab 20mg $3,677.61 $3,687.17 $3,789.63 $3,799.93 J0490 Belimumab 10mg $44.16 $44.16 $44.82 $44.82 J0500 Dicyclomine injection 20mg $69.65 $82.33 $69.97 $57.58 J0515 Inj benztropine mesylate 1mg $18.67 $18.75 $19.89 $17.74 J0570 Buprenorphine implant 74.2mg $1,269.91 $1,263.19 $1,261.87 $1,303.53 J0583 Bivalirudin 1mg $0.80 $0.70 $0.53 $0.62 J0585 Botulinum toxin a per unit 1unit $6.14 $6.12 $6.12 $6.12 J0587 Botulinum toxin type B 100units $12.00 $11.97 $12.02 $11.99 J0592 Buprenorphine hydrochloride 0.1mg $4.15 $4.22 $4.36 $4.56 J0595 Butorphanol tartrate 1 mg 1mg $2.62 $2.51 $2.26 $2.71 J0600 Edetate calcium disodium inj 1000mg $5,594.42 $5,594.42 $5,594.42 $5,594.42 J0610 Calcium gluconate injection 10ml $4.36 $3.22 $3.51 $2.70 J0630 Calcitonin salmon injection 400units $2,651.10 $2,657.54 $2,647.26 $2,661.05 J0636 Inj calcitriol per 0.1 mcg 0.1mcg $0.45 $0.52 $0.72 $0.61 J0637 Caspofungin acetate 5mg $10.02 $10.44 $9.81 $6.85 J0640 Leucovorin calcium injection 50mg $3.35 $3.32 $3.02 $3.02 J0690 Cefazolin sodium injection 500mg $0.83 $0.90 $0.75 $0.77 J0692 Cefepime HCl for injection 500mg $2.47 $1.83 $1.88 $1.91 J0694 Cefoxitin sodium injection 1gm $3.54 $4.50 $4.96 $5.22 J0696 Ceftriaxone sodium injection 250mg $0.65 $0.62 $0.49 $0.54 J0697 Sterile cefuroxime injection 750mg $2.09 $2.14 $1.83 $2.03 J0702 Betamethasone acet&sod phosp 3mg $6.89 $6.81 $6.91 $6.96 J0713 Inj ceftazidime per 500 mg 500mg $2.10 $1.96 $2.00 $2.00 J0717 Certolizum Pegol Inj 1mg $7.89 $7.87 $8.13 $8.02 J0720 Chloramphenicol sodium injec 1gm $39.34 $39.54 $38.33 $38.54 J0725 Chorionic gonadotropin/1000u 1,000units $22.60 $22.21 $22.37 $22.62 J0740 Cidofovir injection 375mg $522.74 $579.91 $643.29 $623.27 J0743 Cilastatin sodium injection 250mg $6.95 $6.29 $5.85 $6.14 J0770 Colistimethate sodium inj 150mg $15.30 $13.47 $19.24 $19.20 J0780 Prochlorperazine injection 10mg $10.06 $9.90 $10.34 $9.69 J0800 Corticotropin injection 1-40units $3,976.02 $3,977.62 $3,962.17 $3,946.50 J0882 Darbepoetin alfa, non-esrd 1mcg $3.83 $3.97 $3.83 $3.85 J0885 Non esrd epoetin alpha inj 1,000units $11.95 $11.73 $11.46 $11.03 J0895 Deferoxamine mesylate inj 500mg $9.62 $8.17 $8.20 $8.52 J0897 Denosumab injection 1 mg $18.61 $18.69 $19.10 $19.28 J1000 Depo-estradiol cypionate inj 5mg $21.94 $21.96 $21.96 $21.89 J1020 Methylprednisolone 20 MG inj 20mg $4.01 $3.89 $3.66 $3.70 J1030 Methylprednisolone 40 MG inj 40mg $6.60 $6.46 $6.24 $6.24 J1040 Methylprednisolone 80 MG inj 80mg $12.86 $12.49 $12.02 $11.93 J1100 Dexamethasone sodium phos 1mg $0.11 $0.10 $0.12 $0.14 J1110 Inj dihydroergotamine mesylt 1mg $14.18 $58.59 $57.29 $57.66 J1120 Acetazolamid sodium injectio 50mg $14.18 $13.76 $15.51 $17.19 J1160 Digoxin injection 0.5mg $4.87 $5.75 $5.21 $5.42 J1165 Phenytoin sodium injection 50mg $1.04 $0.65 $0.75 $0.85 J1190 Dexrazoxane HCl injection 250mg $220.97 $211.49 $194.71 $194.34 J1200 Diphenhydramine hcl injectio 1-50mg $0.54 $0.66 $0.86 $0.91 J1205 Chlorothiazide sodium inj 500mg $73.20 $64.46 $50.64 $49.65 J1230 Methadone injection 10mg $73.20 $18.74 $18.15 $16.54 J1245 Dipyridamole injection 10mg $1.67 $2.19 $1.43 $0.07 J1250 Inj dobutamine HCL/250 mg 250mg $7.32 $8.86 $8.52 $6.99 J1265 DopAMIne injection 40mg $0.82 $0.88 $0.76 $0.76 J1270 Injection, doxercalciferol 1mcg $0.47 $0.30 $0.23 $0.32 J1325 Epoprostenol injection 0.5mg $16.16 $16.14 $16.14 $16.19 J1335 Ertapenem injection 500mg $53.61 $48.49 $44.63 $43.47 J1364 Erythro lactobionate /500 MG 500mg $78.87 $78.87 $78.87 $75.76 J1410 Inj estrogen conjugate 25 MG 25mg $308.91 $309.21 $309.33 $308.93 J1430 Ethanolamine oleate 100 mg 100mg $444.10 $444.10 $444.10 $444.10 J1450 Fluconazole 200mg $5.57 $4.16 $5.17 $4.71 J1566 Inj immune globulin, lyophilzed 500mg 500mg $43.11 $59.81 $62.22 $61.20 J1570 Ganciclovir sodium injection 500mg $56.25 $50.49 $47.07 $48.41 J1580 Garamycin gentamicin inj 80mg $1.69 $1.73 $1.83 $1.91 J1610 Glucagon hydrochloride/1 MG 1mg $219.92 $207.13 $200.26 $199.27 J1626 Granisetron HCl injection 100mcg $0.44 $0.35 $0.30 $0.40 J1630 Haloperidol injection 5mg $1.09 $1.04 $1.13 $0.97 J1631 Haloperidol decanoate inj 50mg $17.39 $16.58 $16.65 $16.48 J1642 Inj heparin sodium per 10 u 10units $0.18 $0.16 $0.17 $0.25 J1644 Inj heparin sodium per 1000u 1000units $0.20 $0.19 $0.20 $0.20 J1645 Dalteparin sodium 2500I.U. $13.94 $13.41 $13.15 $15.58 J1650 Inj enoxaparin sodium 10mg $0.77 $0.87 $0.83 $0.82 J1652 Fondaparinux sodium 0.5mg $2.07 $2.14 $1.74 $1.72 J1720 Hydrocortisone sodium succ i 100mg $12.99 $13.04 $418.84 $12.90 J1740 Ibandronate sodium 1mg $55.44 $44.45 $45.73 $43.48 J1742 Ibutilide fumarate injection 1mg $235.48 $131.54 $152.86 $278.77 J1745 Infliximab injection 10mg $76.95 $71.83 $64.96 $63.28 J1756 Iron sucrose injection 1mg $0.24 $0.23 $0.23 $0.23 J1786 Imuglucerase injection 10units $42.12 $42.10 $42.86 $42.94 J1800 Propranolol injection 1mg $3.66 $3.52 $1.23 $8.48 J1815 Insulin injection 5units $0.89 $0.91 $0.90 $0.88 J1817 Insulin for insulin pump use 50units $10.95 $11.08 $10.99 $10.78 J1940 Furosemide injection 20mg $0.83 $0.80 $0.77 $0.69 J1950 Leuprolide acetate /3.75 MG 3.75mg $1,188.99 $1,190.20 $1,267.77 $1,269.23 J1955 Inj levocarnitine per 1 gm 1gm $20.56 $19.99 $20.14 $19.40 J1956 Levofloxacin injection 250mg $1.47 $1.21 $1.08 $0.22 J1980 Hyoscyamine sulfate inj 0.25mg $30.29 $30.33 $29.55 $29.47 J2001 Lidocaine injection 10mg $0.05 $0.03 $0.03 $0.03 J2010 Lincomycin injection 300mg $13.46 $12.34 $13.16 $11.18 J2020 Linezolid injection 200mg $8.51 $9.05 $6.91 $6.30 J2060 Lorazepam injection 2mg $0.73 $0.73 $0.64 $0.66 J2150 Mannitol injection 50ml $3.80 $3.49 $2.11 $2.62 J2185 Meropenem 100mg $1.03 $1.05 $0.98 $0.90 J2210 Methylergonovin maleate inj 0.2mg $15.77 $16.90 $17.21 $17.39 J2250 Inj midazolam hydrochloride 1mg $0.13 $0.13 $0.11 $0.12 J2260 Inj milrinone lactate / 5 MG 5mg $1.40 $1.44 $2.02 $1.78 J2310 Inj naloxone hydrochloride 1mg $17.72 $14.63 $17.46 $15.28 J2353 Octreotide injection, depot 1mg $197.88 $197.91 $204.69 $206.57 J2354 Octreotide inj, non-depot 25mcg $0.91 $0.87 $0.81 $0.78 J2400 Chloroprocaine hcl injection 30ml $28.78 $27.60 $27.05 $23.32 J2405 Ondansetron hcl injection 1mg $0.17 $0.11 $0.12 $0.11 J2430 Pamidronate disodium /30 MG 30mg $11.91 $16.18 $12.47 $12.06 J2501 Paricalcitol 1mcg $0.64 $0.75 $0.65 $0.79 J2505 Injection, pegfilgrastim 6mg 6mg $4,681.81 $4,655.48 $4,528.31 $4,432.55 J2507 Pegloticase injection 1mg 1mg $2,361.05 $2,403.30 $2,485.24 $2,512.55 J2510 Penicillin g procaine inj 600,000units $29.29 $29.79 $29.82 $29.97 J2515 Pentobarbital sodium inj 50mg $48.29 $44.40 $38.04 $37.01 J2543 Piperacillin/tazobactam 1.125gm $1.94 $1.96 $1.82 $1.83 J2560 Phenobarbital sodium inj 120mg $39.20 $39.42 $41.43 $42.04 J2597 Inj desmopressin acetate 1mcg $12.46 $12.35 $11.97 $12.14 J2675 Inj progesterone per 50 MG 50mg $1.85 $1.78 $2.26 $2.21 J2680 Fluphenazine decanoate 25 MG 25mg $15.44 $12.43 $11.45 $10.95 J2690 Procainamide hcl injection 1gm $77.30 $82.22 $70.14 $77.49 J2700 Oxacillin sodium injection 250mg $1.93 $1.60 $1.48 $1.37 J2765 Metoclopramide hcl injection 10mg $1.92 $1.25 $1.25 $1.54 J2770 Quinupristin/dalfopristin 500mg $417.76 $417.00 $418.10 $417.49 J2780 Ranitidine hydrochloride inj 25mg $5.06 $4.78 $4.53 $4.09 J2783 Rasburicase 0.5mg $279.82 $279.16 $287.64 $289.81 J2788 Rho d immune globulin 50 mcg 50mcg $28.62 $25.82 $23.61 $24.92 J2792 Rho(D) immune globulin h, sd 100IU $27.78 $28.61 $30.10 $29.78 J2795 Ropivacaine HCl injection 1mg $0.09 $0.08 $0.08 $0.07 J2810 Inj theophylline per 40 MG 40mg $0.33 $0.37 $0.42 $0.42 J2820 Sargramostim injection 50mcg $38.96 $39.67 $42.40 $43.44 J2916 Na ferric gluconate complex 12.5mg $1.94 $1.90 $1.73 $1.62 J2920 Methylprednisolone injection 40mg $4.87 $4.46 $4.49 $4.49 J2930 Methylprednisolone injection 125mg $6.93 $6.36 $6.17 $6.12 J2997 Alteplase recombinant 1mg $87.75 $87.68 $87.69 $87.64 J3010 Fentanyl citrate injection 0.1mg $0.83 $0.77 $0.81 $0.89 J3101 Tenecteplase injection 1mg $121.81 $121.78 $121.79 $121.82 J3105 Terbutaline sulfate inj 1mg $2.68 $3.18 $2.56 $1.63 J3230 Chlorpromazine hcl injection 50mg $30.34 $29.19 $33.20 $31.61 J3240 Thyrotropin injection 0.9mg_1.1mg $1,653.59 $1,652.12 $1,690.30 $1,695.12 J3250 Trimethobenzamide hcl inj 200mg $32.77 $33.58
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