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 2 * 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
J0185 - Injection, aprepitant, 1 mg 1 MG 1.731 20% - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 2283.728 20% - - - - -
J0206 - Injection, allopurinol sodium, 1 mg 1 MG 5.805 20% - - - - -
J0216 - Injection, alfentanil hydrochloride, 500 micrograms 500 MCG 2.565 20% - - - - -
J0218 - Injection, olipudase alfa-rpcp, 1 mg 1 MG 377.508 20% - - - - -
J0219 - Injection, avalglucosidase alfa-ngpt, 4 mg 4 MG 75.038 20% - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 194.915 20% - - - - -
J0222 - Injection, patisiran, 0.1 mg 0.1 MG 100.472 20% - - - - -
J0223 - Injection, givosiran, 0.5 mg 0.5 MG 112.486 20% - - - - -
J0224 - Injection, lumasiran, 0.5 mg 0.5 MG 318.998 20% - - - - -
J0225 - Injection, vutrisiran, 1 mg 1 MG 4940.95 20% - - - - -
J0248 - Injection, remdesivir, 1 mg 1 MG 6.058 20% - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.878 20% - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 5.311 20% - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 0.936 20% - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 4.508 20% - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 41.673 20% - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 11.13 19.368% - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 27.871 20% - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.782 20% - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.356 20% - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 1.89 20% - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.479 20% - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 5.714 20% - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 6.723 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