Medicare Part B Drug Payment Limits
Every quarter CMS republishes what Medicare will pay for each Part B drug code, and the number changes. This tool reads the current Part B Drug Payment Limit File so you can check the allowance for a HCPCS code, the dosage that code represents, the coinsurance percentage, and whether the drug is payable under Part B at all.
- 893Part B drug codes in the current file
- QuarterlyLimits are replaced every three months
- 7Codes flagged as not payable under Part B
- FreeNo login, runs in your browser
Why the number moves every quarter
Medicare pays for most Part B drugs using the average sales price methodology. Manufacturers report sales data to CMS, CMS calculates a payment allowance from it, and the result is republished four times a year. A limit you looked up in July is not the limit in October, and billing from a stale rate sheet is a common cause of underpayment that nobody notices because the claim still pays, just not at the right amount.
The allowance shown here is the national figure. What actually lands on a remittance is adjusted for your locality and, where applicable, reduced by sequestration. Treat this as the published starting point rather than an expected payment.
The coinsurance column is worth reading
Most Part B drugs carry the standard 20% patient coinsurance, but not all of them do, and the file states the percentage for each code. Where a drug falls under a different arrangement the figure differs, which changes the patient responsibility you should be estimating up front. The tool calculates the per-unit patient share for you from those two columns.
Not payable is a different answer from not listed
CMS publishes a short companion list of drugs that are not payable under Part B. Those codes are folded into this tool and flagged, because a biller searching a code and finding nothing cannot tell the difference between a code that does not exist, a code paid under Part D, and a code CMS has explicitly ruled out. Seeing the explicit flag is a faster answer than an empty result.
Sources and methodology
Source: the CMS Medicare Part B Drug Payment Limit File, published quarterly. This tool reads the section 508 comma-delimited version of the payment limit file and the companion drugs-not-payable file from the same release, and shows the effective period printed inside the file rather than an assumed date.
Payment limit and coinsurance are reproduced as published. Patient share per unit is the payment limit multiplied by the coinsurance percentage. No figure is estimated, rounded beyond the published precision, or adjusted for locality.
Only HCPCS Level II drug codes appear here. CPT-coded services are not included, and no CPT content is reproduced anywhere on this page.