ASP Drug Pricing - (3rd Quarter)
July 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2023 (1st 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 Jul 1, 2023 through Sep 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 0.135 20% - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.451 20% - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.813 20% - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.833 20% - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.547 20% - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.73 20% - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.345 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 3.683 20% - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.133 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 43.271 20% - - - - -
J0131 - Injection, acetaminophen, not otherwise specified,10 mg 10 MG 0.086 20% - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 0.779 20% - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.047 20% - - - - -
J0134 - Injection, acetaminophen (fresenius kabi) not therapeutically equivalent to j0131, 10 mg 10 MG 0.069 20% - - - - -
J0136 - Injection, acetaminophen (b braun) not therapeutically equivalent to j0131, 10 mg 10 MG 0.054 20% - - - - -
J0137 - Injection, acetaminophen (hikma) not therapeutically equivalent to j0131, 10 mg 10 MG 0.075 20% - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.54 20% - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.733 20% - - - - -
J0172 - Injection, aducanumab-avwa, 2 mg 2 MG 5.978 20% - - - - -
J0173 - Injection, epinephrine (belcher) not therapeutically equivalent to j0171, 0.1 mg 0.1 MG 1.614 20% - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 875.67 20% - - - - -
J0179 - Injection, brolucizumab-dbll, 1 mg 1 MG 319.946 20% - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 215.378 20% - - - - -
* Effective Jul 1, 2023 through Sep 30, 2023

Drugs not otherwise classified - July 2023

 

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

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.305
Aztreonam 500 MG 14.775
Bumetanide 0.25 MG 0.383
Carmustine (Accord) 100 MG 654.42
Diltiazem Hydrochloride 5 MG 0.342
Doxycycline Hyclate 100 MG 16.063
Famotidine 10 MG 0.417
Flumazenil 0.1 MG 0.812
Folic Acid 5 MG 2.586
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.348 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 4.852 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.151
Olanzapine short acting intramuscular injection 0.5 MG 0.9
Rifampin 600 MG 111.851
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.763
Sulfamethoxazole-Trimethoprim 400-80 MG 0.892

ASP (Average Sale Price) Drug Pricing History