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 23 * 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
J9196 - Injection, gemcitabine hydrochloride (accord), not therapeutically equivalent to j9201, 200 mg 200 MG 3.715 20% - - - - -
J9198 - Injection, gemcitabine hydrochloride, (infugem), 100 mg 100 MG 40.28 19.397% - - - - -
J9200 - Injection, floxuridine, 500 mg 500 MG 3551 20% - - - - -
J9201 - Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg 200 MG 3.706 20% - - - - -
J9202 - Goserelin acetate implant, per 3.6 mg 3.6 MG 613.565 20% - - - - -
J9203 - Injection, gemtuzumab ozogamicin, 0.1 mg 0.1 MG 221.843 20% - - - - -
J9204 - Injection, mogamulizumab-kpkc, 1 mg 1 MG 226.706 20% - - - - -
J9205 - Injection, irinotecan liposome, 1 mg 1 MG 61.964 20% - - - - -
J9206 - Injection, irinotecan, 20 mg 20 MG 3.003 20% - - - - -
J9207 - Injection, ixabepilone, 1 mg 1 MG 122.548 20% - - - - -
J9208 - Injection, ifosfamide, 1 gram 1 GM 25.384 20% - - - - -
J9209 - Injection, mesna, 200 mg 200 MG 1.669 20% - - - - -
J9210 - Injection, emapalumab-lzsg, 1 mg 1 MG 393.723 20% - - - - -
J9211 - Injection, idarubicin hydrochloride, 5 mg 5 MG 33.898 20% - - - - -
J9214 - Injection, interferon, alfa-2b, recombinant, 1 million units 1 MIL UNITS 32.574 20% - - - - -
J9217 - Leuprolide acetate (for depot suspension), 7.5 mg 7.5 MG 165.863 20% - - - - -
J9218 - Leuprolide acetate, per 1 mg 1 MG 10.057 20% - - - - -
J9223 - Injection, lurbinectedin, 0.1 mg 0.1 MG 197.177 20% - - - - -
J9226 - Histrelin implant (supprelin la), 50 mg 50 MG 43270.018 20% - - - - -
J9227 - Injection, isatuximab-irfc, 10 mg 10 MG 74.349 20% - - - - -
J9228 - Injection, ipilimumab, 1 mg 1 MG 167.933 20% - - - - -
J9229 - Injection, inotuzumab ozogamicin, 0.1 mg 0.1 MG 2529.553 20% - - - - -
J9245 - Injection, melphalan hydrochloride, not otherwise specified, 50 mg 50 MG 154.188 20% - - - - -
J9246 - Injection, melphalan (evomela), 1 mg 1 MG 16.441 20% - - - - -
J9250 - Methotrexate sodium, 5 mg 5 MG 0.274 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