Table III: 2021 Medicare Drug Fee Schedule* CY 2021 3rd Quarter Average Sales Price (ASP) Data Plus 6 Percent *The Medicare payments allowance limits are effective July 1 - September 30, 2021 CY 2021 CY 2021 CY 2021 Effective Jan. 1 Effective Apr. 1 Effective July 1 Through Mar. 31 Through June 30 Through Sep. 30 Code Description Code Dosage ASP plus 6 percent ASP plus 6 percent ASP plus 6 percent J0129 Abatacept 10mg $56.87 $57.83 $45.32 J0133 Acyclovir, 5 mg 5mg $0.04 $0.03 $0.04 J0171 Adrenalin epinephrin inject 0.1mg $0.85 $0.84 $0.80 J0207 Amifostine 500mg $1,135.69 $1,135.69 $1,135.69 J0256 Alpha 1 proteinase inhibitor 10mg $4.52 $4.51 $4.56 J0280 Aminophyllin 250 MG inj 250mg $10.34 $9.50 $6.11 J0289 Amphotericin b liposome inj 10mg $27.24 $27.07 $28.33 J0295 Ampicillin sodium per 1.5 gm 1.5gm $2.46 $2.75 $2.79 J0360 Hydralazine hcl injection 20mg $2.94 $4.87 $5.69 J0456 Azithromycin 500mg $3.30 $4.58 $3.88 J0461 Atropine sulfate injection 0.01mg $0.08 $0.09 $0.10 J0475 Baclofen 10 MG injection 10mg $172.78 $179.01 $179.42 J0476 Baclofen intrathecal trial 50mcg $56.66 $57.06 $58.45 J0480 Basiliximab 20mg $4,019.07 $4,016.20 $4,029.23 J0490 Belimumab 10mg $46.84 $46.87 $47.58 J0500 Dicyclomine injection 20mg $34.64 $33.85 $29.12 J0515 Inj benztropine mesylate 1mg $17.16 $17.41 $17.33 J0570 Buprenorphine implant 74.2mg $1,204.99 $1,285.78 $1,311.75 J0583 Bivalirudin 1mg $0.45 $0.60 $0.34 J0585 Botulinum toxin a per unit 1unit $6.06 $6.06 $6.08 J0587 Botulinum toxin type B 100units $11.97 $11.97 $11.57 J0592 Buprenorphine hydrochloride 0.1mg $4.49 $4.32 $4.30 J0595 Butorphanol tartrate 1 mg 1mg $2.96 $3.02 $3.02 J0600 Edetate calcium disodium inj 1000mg $5,594.42 $5,592.56 $5,708.59 J0610 Calcium gluconate injection 10ml $3.85 $3.63 $4.34 J0630 Calcitonin salmon injection 400units $2,830.55 $2,801.01 $3,036.61 J0636 Inj calcitriol per 0.1 mcg 0.1mcg $0.74 $0.74 $0.72 J0637 Caspofungin acetate 5mg $6.65 $8.80 $6.99 j0638 Canakinumab Inj 1mg $113.26 $113.32 $115.42 J0640 Leucovorin calcium injection 50mg $3.01 $3.22 $3.63 J0690 Cefazolin sodium injection 500mg $0.82 $0.82 $0.80 J0692 Cefepime HCl for injection 500mg $1.81 $1.91 $1.89 J0694 Cefoxitin sodium injection 1gm $6.79 $5.78 $5.18 J0696 Ceftriaxone sodium injection 250mg $0.56 $0.54 $0.56 J0697 Sterile cefuroxime injection 750mg $1.90 $1.99 $2.02 J0702 Betamethasone acet&sod phosp 3mg $7.21 $6.09 $6.63 J0713 Inj ceftazidime per 500 mg 500mg $1.98 $2.01 $1.90 J0717 Certolizum Pegol Inj 1mg $8.18 $8.08 $6.52 J0720 Chloramphenicol sodium injec 1gm $35.21 $35.21 $36.05 J0725 Chorionic gonadotropin/1000u 1,000units $22.82 $21.81 $24.65 J0740 Cidofovir injection 375mg $590.29 $623.28 $589.78 J0743 Cilastatin sodium injection 250mg $7.03 $7.53 $7.64 J0770 Colistimethate sodium inj 150mg $13.85 $16.37 $16.14 J0780 Prochlorperazine injection 10mg $5.07 $5.06 $5.18 J0800 Corticotropin injection 1-40units $4,017.74 $3,898.63 $3,859.01 J0882 Darbepoetin alfa, non-esrd 1mcg $3.56 $3.31 $3.20 J0885 Non esrd epoetin alpha inj 1,000units $8.82 $8.54 $8.22 J0895 Deferoxamine mesylate inj 500mg $7.90 $8.63 $8.60 J0897 Denosumab injection 1 mg $20.11 $20.09 $20.97 J1000 Depo-estradiol cypionate inj 5mg $24.05 $24.05 $24.15 J1020 Methylprednisolone 20 MG inj 20mg $3.35 $3.21 $3.03 J1030 Methylprednisolone 40 MG inj 40mg $5.80 $5.74 $5.55 J1040 Methylprednisolone 80 MG inj 80mg $10.76 $10.74 $10.41 J1100 Dexamethasone sodium phos 1mg $0.14 $0.16 $0.17 J1110 Inj dihydroergotamine mesylt 1mg $57.27 $56.48 $43.47 J1120 Acetazolamid sodium injectio 50mg $23.38 $34.46 $31.21 J1160 Digoxin injection 0.5mg $4.94 $5.12 $5.65 J1165 Phenytoin sodium injection 50mg $0.56 $0.42 $0.46 J1190 Dexrazoxane HCl injection 250mg $195.98 $207.49 $194.98 J1200 Diphenhydramine hcl injectio 1-50mg $0.62 $1.03 $0.95 J1205 Chlorothiazide sodium inj 500mg $52.43 $65.70 $67.34 J1230 Methadone injection 10mg $17.95 $18.03 $17.60 J1245 Dipyridamole injection 10mg $3.36 $3.53 $3.44 J1250 Inj dobutamine HCL/250 mg 250mg $7.19 $7.71 $6.96 J1265 DopAMIne injection 40mg $0.66 $0.71 $0.72 J1270 Injection, doxercalciferol 1mcg $0.32 $0.49 $0.46 J1325 Epoprostenol injection 0.5mg $16.43 $16.45 $16.22 J1335 Ertapenem injection 500mg $32.16 $29.99 $28.13 J1364 Erythro lactobionate /500 MG 500mg $73.74 $76.71 $78.74 J1410 Inj estrogen conjugate 25 MG 25mg $325.51 $325.46 $341.77 J1430 Ethanolamine oleate 100 mg 100mg $444.10 $444.10 $444.10 J1450 Fluconazole 200mg $3.32 $3.17 $3.96 J1566 Inj immune globulin, lyophilzed 500mg 500mg $66.97 $64.22 $65.89 J1570 Ganciclovir sodium injection 500mg $46.50 $45.63 $49.04 J1580 Garamycin gentamicin inj 80mg $1.78 $1.95 $1.89 J1610 Glucagon hydrochloride/1 MG 1mg $194.42 $203.80 $177.45 J1626 Granisetron HCl injection 100mcg $0.22 $0.32 $0.27 J1630 Haloperidol injection 5mg $0.89 $1.43 $1.81 J1631 Haloperidol decanoate inj 50mg $14.16 $13.29 $11.54 J1642 Inj heparin sodium per 10 u 10units $0.01 $0.02 $0.02 J1644 Inj heparin sodium per 1000u 1000units $0.32 $0.27 $0.30 J1645 Dalteparin sodium 2500I.U. $9.47 $8.93 $8.63 J1650 Inj enoxaparin sodium 10mg $0.80 $0.71 $0.76 J1652 Fondaparinux sodium 0.5mg $1.71 $2.05 $1.64 J1720 Hydrocortisone sodium succ i 100mg $14.15 $14.21 $14.77 J1740 Ibandronate sodium 1mg $41.54 $38.55 $37.06 J1742 Ibutilide fumarate injection 1mg $273.16 $262.41 $226.10 J1745 Infliximab injection 10mg $44.90 $41.95 $41.32 J1756 Iron sucrose injection 1mg $0.22 $0.23 $0.22 J1786 Imuglucerase injection 10units $43.38 $43.43 $43.96 J1800 Propranolol injection 1mg $3.45 $2.86 $3.32 J1815 Insulin injection 5units $0.89 $0.90 $0.87 J1817 Insulin for insulin pump use 50units $10.90 $10.79 $10.75 J1940 Furosemide injection 20mg $0.65 $0.77 $0.55 J1950 Leuprolide acetate /3.75 MG 3.75mg $1,582.13 $1,268.00 $1,307.48 J1955 Inj levocarnitine per 1 gm 1gm $20.99 $21.07 $20.99 J1956 Levofloxacin injection 250mg $0.39 $0.38 $0.67 J1980 Hyoscyamine sulfate inj 0.25mg $30.69 $30.62 $30.46 J2001 Lidocaine injection 10mg $0.02 $0.03 $0.03 J2010 Lincomycin injection 300mg $13.21 $11.66 $11.65 J2020 Linezolid injection 200mg $7.07 $7.52 $7.39 J2060 Lorazepam injection 2mg $0.72 $0.71 $0.76 J2150 Mannitol injection 50ml $2.38 $1.98 $2.07 J2185 Meropenem 100mg $0.76 $0.79 $0.82 J2210 Methylergonovin maleate inj 0.2mg $19.31 $18.90 $19.27 J2250 Inj midazolam hydrochloride 1mg $0.12 $0.11 $0.12 J2260 Inj milrinone lactate / 5 MG 5mg $1.75 $2.01 $2.01 J2310 Inj naloxone hydrochloride 1mg $11.94 $12.86 $12.77 J2353 Octreotide injection, depot 1mg $205.66 $205.04 $205.11 J2354 Octreotide inj, non-depot 25mcg $0.74 $1.03 $1.04 J2357 Omalizumab Inj. 1mg $37.42 $37.17 $37.89 J2400 Chloroprocaine hcl injection 30ml $31.40 $28.59 $39.54 J2405 Ondansetron hcl injection 1mg $0.09 $0.10 $0.09 J2430 Pamidronate disodium /30 MG 30mg $10.70 $10.15 $8.31 J2501 Paricalcitol 1mcg $0.60 $1.05 $0.56 J2505 Injection, pegfilgrastim 6mg 6mg $3,079.49 $2,808.06 $2,469.36 J2507 Pegloticase injection 1mg 1mg $2,771.29 $2,799.66 $2,900.42 J2510 Penicillin g procaine inj 600,000units $29.86 $29.82 $31.10 J2515 Pentobarbital sodium inj 50mg $29.87 $33.91 $27.62 J2543 Piperacillin/tazobactam 1.125gm $1.61 $1.51 $1.42 J2560 Phenobarbital sodium inj 120mg $45.66 $45.51 $44.95 J2597 Inj desmopressin acetate 1mcg $10.57 $10.09 $9.86 J2675 Inj progesterone per 50 MG 50mg $1.20 $1.41 $1.47 J2680 Fluphenazine decanoate 25 MG 25mg $11.62 $12.88 $11.59 J2690 Procainamide hcl injection 1gm $81.75 $84.37 $76.85 J2700 Oxacillin sodium injection 250mg $1.22 $1.29 $1.27 J2765 Metoclopramide hcl injection 10mg $1.08 $1.13 $1.12 J2770 Quinupristin/dalfopristin 500mg $458.83 $459.04 $456.88 J2780 Ranitidine hydrochloride inj 25mg $6.12 $6.12 $6.12 J2783 Rasburicase 0.5mg $306.14 $307.11 $316.06 J2788 Rho d immune globulin 50 mcg 50mcg $24.78 $23.10 $22.20 J2792 Rho(D) immune globulin h, sd 100IU $29.40 $31.57 $30.03 J2795 Ropivacaine HCl injection 1mg $0.07 $0.08 $0.08 J2820 Sargramostim injection 50mcg $48.83 $48.41 $49.51 J2916 Na ferric gluconate complex 12.5mg $2.01 $1.94 $2.16 J2920 Methylprednisolone injection 40mg $4.38 $4.28 $4.03 J2930 Methylprednisolone injection 125mg $5.49 $5.79 $5.45 J2997 Alteplase recombinant 1mg $87.43 $87.68 $87.41 J3010 Fentanyl citrate injection 0.1mg $0.72 $0.67 $0.62 J3101 Tenecteplase injection 1mg $129.27 $129.17 $134.81 J3105 Terbutaline sulfate inj 1mg $5.15 $1.98 $1.37 J3230 Chlorpromazine hcl injection 50mg $35.89 $34.98 $34.72 J3240 Thyrotropin injection 0.9mg_1.1mg $1,776.21 $1,774.33 $1,841.18 J3250 Trimethobenzamide hcl inj 200mg $40.53 $40.61 $40.71 J3260 Tobramycin sulfate injection 80mg $4.60 $4.94 $4.05 J3262 Tocilizumab injection 1mg $5.47 $5.51 $5.53 J3285 Treprostinil, 1 mg 1mg $64.03 $62.56 $60.38 J3301 Triamcinolone acetonide inj 10mg $1.38 $1.29 $1.23 J3304 I(nj.