ASP Drug Pricing - (4th Quarter)
October 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2023 (2nd 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 October 1, 2023 - December 31, 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 0.123 20% - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.403 20% - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.819 20% - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.821 20% - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.531 20% - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.75 20% - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.324 20% - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1265.417 20% - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A 20% - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 3.604 20% - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.126 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 42.7 20% - - - - -
J0131 - Injection, acetaminophen, not otherwise specified,10 mg 10 MG 0.072 20% - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 0.653 20% - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.051 20% - - - - -
J0134 - Injection, acetaminophen (fresenius kabi) not therapeutically equivalent to j0131, 10 mg 10 MG 0.05085316 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 0.067 20% - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.536 20% - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.78 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 1.706 20% - - - - -
J0174 - Injection, lecanemab-irmb, 1 mg 1 MG 1.35 20% - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 868.241 20% - - - - -
J0179 - Injection, brolucizumab-dbll, 1 mg 1 MG 319.249 20% - - - - -
* Effective October 1, 2023 - December 31, 2023

Drugs not otherwise classified - October 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2023 - December 31, 2023

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.287
Aztreonam 500 MG 14.712
Bumetanide 0.25 MG 0.391
Carmustine (Accord) 100 MG 594.083
Diltiazem Hydrochloride 5 MG 0.342
Doxycycline Hyclate 100 MG 15.616
Famotidine 10 MG 0.408
Flumazenil 0.1 MG 0.795
Folic Acid 5 MG 2.905
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.345 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 4.884 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.14171822859631
Rifampin 600 MG 84.394
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.692
Sulfamethoxazole-Trimethoprim 400-80 MG 0.636

ASP (Average Sale Price) Drug Pricing History