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 18 * 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
J7207 - Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. 1 IU 2.106 20% - - - - -
J7208 - Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. 1 IU 2.354 20% - - - - -
J7209 - Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. 1 IU 1.358 20% - - - - -
J7210 - Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u. 1 IU 1.436 20% - - - - -
J7211 - Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u. 1 IU 1.436 20% - - - - -
J7212 - Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram 1 MCG 2.013 20% - - - - -
J7213 - Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. 1 IU 1.746 20% - - - - -
J7308 - Aminolevulinic acid hcl for topical administration, 20%, single unit dosage form (354 mg) 354 MG 391.23 20% - - - - -
J7311 - Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01 mg 0.01 MG 322.381 20% - - - - -
J7312 - Injection, dexamethasone, intravitreal implant, 0.1 mg 0.1 MG 204.677 20% - - - - -
J7313 - Injection, fluocinolone acetonide, intravitreal implant (iluvien), 0.01 mg 0.01 MG 490.947 20% - - - - -
J7314 - Injection, fluocinolone acetonide, intravitreal implant (yutiq), 0.01 mg 0.01 MG 529.269 20% - - - - -
J7318 - Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg 1 MG 6.061 20% - - - - -
J7320 - Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg 1 MG 6.105 20% - - - - -
J7321 - Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose per dose 73.48 20% - - - - -
J7322 - Hyaluronan or derivative, hymovis or hymovis one, for intra-articular injection, 1 mg 1 MG 17.019 20% - - - - -
J7323 - Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose per dose 131.42 20% - - - - -
J7324 - Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose PER DOSE 117.377 20% - - - - -
J7325 - Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg 1 MG 9.617 20% - - - - -
J7326 - Hyaluronan or derivative, gel-one, for intra-articular injection, per dose per dose 516.727 20% - - - - -
J7327 - Hyaluronan or derivative, monovisc, for intra-articular injection, per dose PER DOSE 692.752 20% - - - - -
J7328 - Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg 0.1 MG 0.615 20% - - - - -
J7329 - Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg 1 MG 8.795 20% - - - - -
J7331 - Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg 1 MG 13.25 20% - - - - -
J7332 - Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg 1 MG 10.055 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