ASP Drug Pricing - (2nd Quarter)
April 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2022 (4th 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 25 * Effective April 1, 2023 through June 30, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J9355 - Injection, trastuzumab, excludes biosimilar, 10 mg 10 MG 80.249 20% - - - - -
J9356 - Injection, trastuzumab, 10 mg and hyaluronidase-oysk 10 MG 65.077 20% - - - - -
J9357 - Injection, valrubicin, intravesical, 200 mg 200 MG 1442.534 20% - - - - -
J9358 - Injection, fam-trastuzumab deruxtecan-nxki, 1 mg 1 MG 25.631 20% - - - - -
J9359 - Injection, loncastuximab tesirine-lpyl, 0.075 mg 0.075 MG 191.423 20% - - - - -
J9360 - Injection, vinblastine sulfate, 1 mg 1 MG 3.98787469 20% - - - - -
J9370 - Vincristine sulfate, 1 mg 1 MG 4.847 20% - - - - -
J9390 - Injection, vinorelbine tartrate, 10 mg 10 MG 7.447 20% - - - - -
J9393 - Injection, fulvestrant (teva), not therapeutically equivalent to j9395, 25 mg 25 MG 3.069 20% - - - - -
J9394 - Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg 25 MG 3.915 20% - - - - -
J9395 - Injection, fulvestrant, 25 mg 25 MG 12.086 20% - - - - -
J9400 - Injection, ziv-aflibercept, 1 mg 1 MG 7.389 20% - - - - -
P9041 - Infusion, albumin (human), 5%, 50 ml 50 ML 10.6153 20% - - - - 95 10.6153
P9045 - Infusion, albumin (human), 5%, 250 ml 250 ML 53.0765 20% - - - - 95 53.0765
P9046 - Infusion, albumin (human), 25%, 20 ml 20 ML 21.2306 20% - - - - 95 21.2306
P9047 - Infusion, albumin (human), 25%, 50 ml 50 ML 53.0765 20% - - - - 95 53.0765
Q0138 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) 1 MG 0.478 20% - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.478 20% - - - - -
Q0162 - Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 1 MG 0.012 20% - - - - -
Q0167 - Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 2.5 MG 0.782 20% - - - - -
Q0222 - Injection, bebtelovimab, 175 mg 175 MG 2394 0% - - - - -
Q2041 - Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION CAR T CELLS 449245.861 19.937% - - - - -
Q2043 - Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion Per infusion (minimum 50 million cells) 53630.369 20% - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 78.063 20% - - - - -
Q2053 - Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR POSITIVE VIABLE T CEL 448752.402 19.958% - - - - -
* Effective April 1, 2023 through June 30, 2023

Drugs not otherwise classified - April 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2023 through June 30, 2023

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.235
Allopurinol Sodium 500 MG 2979.421
Aminocaproic acid 250 MG 0.285
Aztreonam 500 MG 14.91
Bumetanide 0.25 MG 0.354
Bupivacaine 1 ML 0.143
Carmustine (Accord) 100 MG 723.117 Added April 2023
Clindamycin Phosphate 150 MG 0.997
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.779 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.327
Doxycycline Hyclate 100 MG 16.652
Esmolol Hydrochloride 10 MG 0.278
Famotidine 10 MG 0.405
Flumazenil 0.1 MG 0.969
Folic Acid 5 MG 2.525
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.28 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 5.048 Added April 2023 - providers must check the crosswalk file to determine the correct payment allowance
Immune Globulin (Panzyga) 500 MG 65.821
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 UNITS 7.19
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 UNITS 15.735
Labetalol Hcl 5 MG 0.272
Metoprolol Tartrate 1 MG 0.146
Metronidazole inj 500 MG 1.327
Nitroglycerin 5 MG 1.387
Olanzapine short acting intramuscular injection 0.5 MG 0.998
Paliperidone Palmitate (Invega Trinza) 1 MG 11.657
Rifampin 600 MG 102.954
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.746
Sulfamethoxazole-Trimethoprim 400-80 MG 0.746
Vasopressin 20 UNITS 101.775
Vasopressin (American Regent) 20 UNITS 86.938

ASP (Average Sale Price) Drug Pricing History