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 4 * 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
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 1327.995 20% - - - - -
J0636 - Injection, calcitriol, 0.1 mcg 0.1 MCG 0.761 20% - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 4.887 20% - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 119.821 20% - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 3.406 20% - - - - -
J0642 - Injection, levoleucovorin (khapzory), 0.5 mg 0.5 MG 1.559 20% - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.474 20% - - - - -
J0689 - Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg 500 MG 1.186 20% - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.767 20% - - - - -
J0691 - Injection, lefamulin, 1 mg 1 MG 0.724 20% - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.238 20% - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 5.157 20% - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 6.714 20% - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.513 20% - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 2.241 20% - - - - -
J0701 - Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.359 20% - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.4017487422124 20% - - - - -
J0703 - Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.223 20% - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.765 20% - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 1.855 20% - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 90.838 20% - - - - -
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 4.971 20% - - - - -
J0720 - Injection, chloramphenicol sodium succinate, up to 1 gm 1 GM 40.274 20% - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 22.306 20% - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 22.891 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