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 4 * 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
J0598 - Injection, c-1 esterase inhibitor (human), cinryze, 10 units 10 UNITS 60.725 20% - - - - -
J0612 - Injection, calcium gluconate, not otherwise specified, 10 mg 10 MG 0.051 20% - - - - -
J0613 - Injection, calcium gluconate (wg critical care), not therapeutically equivalent to j0612, 10 mg 10 MG 0.085 20% - - - - -
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 1296.363 20% - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 5.4997300586084 20% - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 122.055 20% - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 4.461 20% - - - - -
J0642 - Injection, levoleucovorin (khapzory), 0.5 mg 0.5 MG 1.057 20% - - - - -
J0665 - Injection, bupivicaine, not otherwise specified, 0.5 mg 0.5 MG 0.016 20% - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 2.452689538689 20% - - - - -
J0689 - Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg 500 MG 1.208 20% - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.727 20% - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.27 20% - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 5.172 20% - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 7.481 20% - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.472 20% - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 1.868 20% - - - - -
J0699 - Injection, cefiderocol, 10 mg 10 mg 2.173 20% - - - - -
J0701 - Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.688 20% - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.406 20% - - - - -
J0703 - Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.092 20% - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.856 20% - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 1.779 20% - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 95.437 20% - - - - -
J0717 - Injection, certolizumab pegol, 1 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) 1 MG 4.9 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