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 5 * 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
J0740 - Injection, cidofovir, 375 mg 375 MG 608.327 20% - - - - -
J0741 - Injection, cabotegravir and rilpivirine, 2mg/3mg 2MG/3MG 21.555 20% - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.382 20% - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 7.11992831318414 20% - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 1.338 20% - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 15.602 20% - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 64.997 18.96% - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 2.978 20% - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 125.281 20% - - - - -
J0800 - Injection, corticotropin, up to 40 units 40 UNITS 3894.404 20% - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 24.779 20% - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 2077.793 20% - - - - -
J0841 - Injection, crotalidae immune f(ab')2 (equine), 120 mg 120 MG 433.19 20% - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1814.619 18.983% - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 15.315 20% - - - - -
J0877 - Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg 1 MG 0.075 20% - - - - -
J0878 - Injection, daptomycin, 1 mg 1 MG 0.041 20% - - - - -
J0881 - Injection, darbepoetin alfa, 1 microgram (non-esrd use) 1 MCG 3.089 20% - - - - -
J0882 - Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) 1 MCG 3.089 20% - - - - -
J0885 - Injection, epoetin alfa, (for non-esrd use), 1000 units 1000 UNITS 7.928 20% - - - - -
J0887 - Injection, epoetin beta, 1 microgram, (for esrd on dialysis) 1 MCG 1.969 20% - - - - -
J0888 - Injection, epoetin beta, 1 microgram, (for non esrd use) 1 MCG 1.969 17.614% - - - - -
J0891 - Injection, argatroban (accord), not therapeutically equivalent to j0883, 1 mg (for non-esrd use) 1 MG 0.415 20% - - - - -
J0892 - Injection, argatroban (accord), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis) 1 MG 0.415 20% - - - - -
J0893 - Injection, decitabine (sun pharma) not therapeutically equivalent to j0894, 1 mg 1 MG 1.881 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