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 11 * 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
J1954 - Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg 7.5 MG 425.478 20% - - - - -
J1955 - Injection, levocarnitine, per 1 gm 1 GM 35.415 13.558% - - - - -
J1956 - Injection, levofloxacin, 250 mg 250 MG 0.917 20% - - - - -
J1980 - Injection, hyoscyamine sulfate, up to 0.25 mg 0.25 MG 33.233 20% - - - - -
J2001 - Injection, lidocaine hcl for intravenous infusion, 10 mg 10 MG 0.03 20% - - - - -
J2010 - Injection, lincomycin hcl, up to 300 mg 300 MG 9.991 20% - - - - -
J2020 - Injection, linezolid, 200 mg 200 MG 3.471 20% - - - - -
J2021 - Injection, linezolid (hospira), not therapeutically equivalent to j2020, 200 mg 200 MG 9.48 20% - - - - -
J2060 - Injection, lorazepam, 2 mg 2 MG 0.852 20% - - - - -
J2150 - Injection, mannitol, 25% in 50 ml 50 ML 4.93 20% - - - - -
J2175 - Injection, meperidine hydrochloride, per 100 mg 100 MG 7.309 20% - - - - -
J2182 - Injection, mepolizumab, 1 mg 1 MG 29.747 20% - - - - -
J2184 - Injection, meropenem (b. braun), not therapeutically equivalent to j2185, 100 mg 100 MG 2.101 20% - - - - -
J2185 - Injection, meropenem, 100 mg 100 MG 0.518 20% - - - - -
J2210 - Injection, methylergonovine maleate, up to 0.2 mg 0.2 MG 20.893 20% - - - - -
J2247 - Injection, micafungin sodium (par pharm) not thereapeutically equivalent to j2248, 1 mg 1 MG 0.291 20% - - - - -
J2248 - Injection, micafungin sodium, 1 mg 1 MG 0.83 20% - - - - -
J2250 - Injection, midazolam hydrochloride, per 1 mg 1 MG 0.14 20% - - - - -
J2251 - Injection, midazolam in 0.9% sodium chloride, intravenous, not therapeutically equivalent to j2250, 1 mg 1 MG 0.288 20% - - - - -
J2260 - Injection, milrinone lactate, 5 mg 5 MG 1.874 20% - - - - -
J2270 - Injection, morphine sulfate, up to 10 mg 10 MG 4.6 20% - - - - -
J2272 - Injection, morphine sulfate (fresenius kabi), not therapeutically equivalent to j2270, up to 10 mg 10 MG 6.929 20% - - - - -
J2274 - Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 10 MG 15.701 20% - - - - -
J2278 - Injection, ziconotide, 1 microgram 1 MCG 9.078 20% - - - - -
J2280 - Injection, moxifloxacin, 100 mg 100 MG 9.845 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