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 17 * 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
J7177 - Injection, human fibrinogen concentrate (fibryga), 1 mg 1 MG 1.098 20% - - - - -
J7178 - Injection, human fibrinogen concentrate, not otherwise specified, 1 mg 1 IU 1.383 20% - - - - -
J7179 - Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco 1 IU 1.781 20% - - - - -
J7180 - Injection, factor xiii (antihemophilic factor, human), 1 i.u. 1 IU 9.683 20% - - - - -
J7181 - Injection, factor xiii a-subunit, (recombinant), per iu 1 IU 16.886 20% - - - - -
J7182 - Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu 1 IU 1.283 20% - - - - -
J7183 - Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco 1 I.U. VWF:RCO 1.259 20% - - - - -
J7185 - Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. 1 IU 1.376 20% - - - - -
J7186 - Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. PER FACTOR VIII IU 1.216 20% - - - - -
J7187 - Injection, von willebrand factor complex (humate-p), per iu vwf:rco 1 IU 1.347 20% - - - - -
J7188 - Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. 1 IU 3.217 20% - - - - -
J7189 - Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram 1 MCG 2.412 20% - - - - -
J7190 - Factor viii (antihemophilic factor, human) per i.u. 1 IU 1.029 20% - - - - -
J7192 - Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified 1 IU 1.506 20% - - - - -
J7193 - Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. 1 IU 1.297 19.929% - - - - -
J7194 - Factor ix, complex, per i.u. 1 IU 1.615 20% - - - - -
J7195 - Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified 1 IU 1.756 20% - - - - -
J7197 - Antithrombin iii (human), per i.u. 1 IU 3.35 20% - - - - -
J7198 - Anti-inhibitor, per i.u. 1 IU 2.232 20% - - - - -
J7200 - Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu 1 IU 1.614 20% - - - - -
J7201 - Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. 1 IU 3.46 20% - - - - -
J7202 - Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. 1 IU 4.932 20% - - - - -
J7203 - Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu 1 MG 4.414 20% - - - - -
J7204 - Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu 1 IU 2.108 20% - - - - -
J7205 - Injection, factor viii fc fusion protein (recombinant), per iu 1 IU 2.173 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