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 13 * 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
J2506 - Injection, pegfilgrastim, excludes biosimilar, 0.5 mg 0.5 MG 85.71 20% - - - - -
J2507 - Injection, pegloticase, 1 mg 1 MG 3268.45 20% - - - - -
J2510 - Injection, penicillin g procaine, aqueous, up to 600,000 units 600000 UNITS 43.376 20% - - - - -
J2540 - Injection, penicillin g potassium, up to 600,000 units 600000 UNITS 1.07 20% - - - - -
J2543 - Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 1.125 GM 1.359 20% - - - - -
J2545 - Pentamidine isethionate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 300 mg 300 MG 93.857 20% - - - - -
J2550 - Injection, promethazine hcl, up to 50 mg 50 MG 3.147 20% - - - - -
J2560 - Injection, phenobarbital sodium, up to 120 mg 120 MG 39.383 20% - - - - -
J2562 - Injection, plerixafor, 1 mg 1 MG 429.363 20% - - - - -
J2597 - Injection, desmopressin acetate, per 1 mcg 1 MCG 7.271 20% - - - - -
J2598 - Injection, vasopressin, 1 unit 1 UNIT 2.919 20% - - - - -
J2599 - Injection, vasopressin (american regent), not therapeutically equivalent to j2598, 1 unit 1 UNIT 2.098 20% - - - - -
J2675 - Injection, progesterone, per 50 mg 50 MG 0.97 20% - - - - -
J2680 - Injection, fluphenazine decanoate, up to 25 mg 25 MG 10.952 20% - - - - -
J2690 - Injection, procainamide hcl, up to 1 gm 1 GM 307.989 20% - - - - -
J2700 - Injection, oxacillin sodium, up to 250 mg 250 MG 1.173 20% - - - - -
J2704 - Injection, propofol, 10 mg 10 MG 0.098 20% - - - - -
J2720 - Injection, protamine sulfate, per 10 mg 10 MG 0.947 20% - - - - -
J2724 - Injection, protein c concentrate, intravenous, human, 10 iu 10 UNITS 15.112 20% - - - - -
J2760 - Injection, phentolamine mesylate, up to 5 mg 5 MG 458.182 20% - - - - -
J2765 - Injection, metoclopramide hcl, up to 10 mg 10 MG 1.235 20% - - - - -
J2777 - Injection, faricimab-svoa, 0.1 mg 0.1 MG 37.089 20% - - - - -
J2778 - Injection, ranibizumab, 0.1 mg 0.1 mg 236.583 20% - - - - -
J2779 - Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg 0.1 MG 81.018 20% - - - - -
J2783 - Injection, rasburicase, 0.5 mg 0.5 MG 357.364 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