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 5 * 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
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 21.778 20% - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 19.585 20% - - - - -
J0736 - Injection, clindamycin phosphate, 300 mg 300 MG 2.015 20% - - - - -
J0737 - Injection, clindamycin phosphate (baxter), not therapeutically equivalent to j0736, 300 mg 300 MG 2.594 20% - - - - -
J0740 - Injection, cidofovir, 375 mg 375 MG 550.376 20% - - - - -
J0741 - Injection, cabotegravir and rilpivirine, 2mg/3mg 2MG/3MG 22.286 20% - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.46 20% - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 7.925 20% - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 1.831 20% - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 13.878 20% - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 67.747 18.6255689507695% - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 2.848 20% - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 126.857 20% - - - - -
J0801 - Injection, corticotropin (acthar gel), up to 40 units 40 UNITS 4090.086 20% - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 32.681 20% - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 2076.463 20% - - - - -
J0841 - Injection, crotalidae immune f(ab')2 (equine), 120 mg 120 MG 1113.511 20% - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1667.586 20% - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 15.214 20% - - - - -
J0877 - Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg 1 MG 0.064 20% - - - - -
J0878 - Injection, daptomycin, 1 mg 1 MG 0.04 20% - - - - -
J0881 - Injection, darbepoetin alfa, 1 microgram (non-esrd use) 1 MCG 2.945 20% - - - - -
J0882 - Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) 1 MCG 2.945 20% - - - - -
J0885 - Injection, epoetin alfa, (for non-esrd use), 1000 units 1000 UNITS 7.092 20% - - - - -
J0887 - Injection, epoetin beta, 1 microgram, (for esrd on dialysis) 1 MCG 1.709 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