ASP Drug Pricing - (2nd Quarter)
April 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2022 (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 1 * Effective April 1, 2023 through June 30, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
A9575 - Injection, gadoterate meglumine, 0.1 ml 0.1 ML 0.169 20% - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.433 20% - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.834 20% - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.84 20% - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.603 20% - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.712 20% - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.34 20% - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1244.44 20% - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A 20% - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 3.624 20% - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.063 20% - - - - -
J0129 - Injection, abatacept, 10 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) 10 MG 42.761 20% - - - - -
J0131 - Injection, acetaminophen, not otherwise specified,10 mg 10 MG 0.099 20% - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 0.762 20% - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.0399796975400708 20% - - - - -
J0134 - Injection, acetaminophen (fresenius kabi) not therapeutically equivalent to j0131, 10 mg 10 MG 0.109 20% - - - - -
J0136 - Injection, acetaminophen (b braun) not therapeutically equivalent to j0131, 10 mg 10 MG 0.052 20% - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.497 20% - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.741 20% - - - - -
J0172 - Injection, aducanumab-avwa, 2 mg 2 MG 5.978 20% - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 893.551 20% - - - - -
J0179 - Injection, brolucizumab-dbll, 1 mg 1 MG 314.855 20% - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 208.166 20% - - - - -
J0185 - Injection, aprepitant, 1 mg 1 MG 1.805 20% - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 2235.38 20% - - - - -
* Effective April 1, 2023 through June 30, 2023

Drugs not otherwise classified - April 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2023 through June 30, 2023

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.235
Allopurinol Sodium 500 MG 2979.421
Aminocaproic acid 250 MG 0.285
Aztreonam 500 MG 14.91
Bumetanide 0.25 MG 0.354
Bupivacaine 1 ML 0.143
Carmustine (Accord) 100 MG 723.117 Added April 2023
Clindamycin Phosphate 150 MG 0.997
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.779 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.327
Doxycycline Hyclate 100 MG 16.652
Esmolol Hydrochloride 10 MG 0.278
Famotidine 10 MG 0.405
Flumazenil 0.1 MG 0.969
Folic Acid 5 MG 2.525
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.28 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 5.048 Added April 2023 - providers must check the crosswalk file to determine the correct payment allowance
Immune Globulin (Panzyga) 500 MG 65.821
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 UNITS 7.19
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 UNITS 15.735
Labetalol Hcl 5 MG 0.272
Metoprolol Tartrate 1 MG 0.146
Metronidazole inj 500 MG 1.327
Nitroglycerin 5 MG 1.387
Olanzapine short acting intramuscular injection 0.5 MG 0.998
Paliperidone Palmitate (Invega Trinza) 1 MG 11.657
Rifampin 600 MG 102.954
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.746
Sulfamethoxazole-Trimethoprim 400-80 MG 0.746
Vasopressin 20 UNITS 101.775
Vasopressin (American Regent) 20 UNITS 86.938

ASP (Average Sale Price) Drug Pricing History