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 4 * 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
J0598 - Injection, c-1 esterase inhibitor (human), cinryze, 10 units 10 UNITS 60.727 20% - - - - -
J0612 - Injection, calcium gluconate, not otherwise specified, 10 mg 10 MG 0.055 20% - - - - -
J0613 - Injection, calcium gluconate (wg critical care), not therapeutically equivalent to j0612, 10 mg 10 MG 0.083 20% - - - - -
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 1366.44 20% - - - - -
J0636 - Injection, calcitriol, 0.1 mcg 0.1 MCG 0.795 20% - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 8.621 20% - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 121.513 20% - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 4.698 20% - - - - -
J0642 - Injection, levoleucovorin (khapzory), 0.5 mg 0.5 MG 1.483 20% - - - - -
J0665 - Injection, bupivicaine, not otherwise specified, 0.5 mg 0.5 MG 0.021 20% - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.077 20% - - - - -
J0689 - Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg 500 MG 1.224 20% - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.869 20% - - - - -
J0691 - Injection, lefamulin, 1 mg 1 MG 0.724 20% - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.226 20% - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 5.001 20% - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 7.54 20% - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.569 20% - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 2.236 20% - - - - -
J0699 - Injection, cefiderocol, 10 mg 10 mg 2.163 20% - - - - -
J0701 - Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.718 20% - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.956 20% - - - - -
J0703 - Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.103 20% - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.887 20% - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 1.836 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