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 24 * 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
J9260 - Injection, methotrexate sodium, 50 mg 50 MG 2.71 20% - - - - -
J9261 - Injection, nelarabine, 50 mg 50 MG 128.994 20% - - - - -
J9262 - Injection, omacetaxine mepesuccinate, 0.01 mg 0.01 MG 4.007 18.895% - - - - -
J9263 - Injection, oxaliplatin, 0.5 mg 0.5 MG 0.068 20% - - - - -
J9264 - Injection, paclitaxel protein-bound particles, 1 mg 1 MG 12.056 20% - - - - -
J9266 - Injection, pegaspargase, per single dose vial 1 EA 25762.46 19.129% - - - - -
J9267 - Injection, paclitaxel, 1 mg 1 MG 0.122 20% - - - - -
J9268 - Injection, pentostatin, 10 mg 10 MG 2387.725 18.882% - - - - -
J9269 - Injection, tagraxofusp-erzs, 10 micrograms 10 MCG 322.596 20% - - - - -
J9271 - Injection, pembrolizumab, 1 mg 1 MG 54.811 20% - - - - -
J9272 - Injection, dostarlimab-gxly, 10 mg 10 MG 226.925 20% - - - - -
J9273 - Injection, tisotumab vedotin-tftv, 1 mg 1 MG 162.051 20% - - - - -
J9274 - Injection, tebentafusp-tebn, 1 microgram 1 MCG 203.827 20% - - - - -
J9280 - Injection, mitomycin, 5 mg 5 MG 79.024 20% - - - - -
J9281 - Mitomycin pyelocalyceal instillation, 1 mg 1 MG 296.173 20% - - - - -
J9293 - Injection, mitoxantrone hydrochloride, per 5 mg 5 MG 29.06 20% - - - - -
J9294 - Injection, pemetrexed (hospira), not therapeutically equivalent to j9305, 10 mg 10 MG 9.997 20% - - - - -
J9295 - Injection, necitumumab, 1 mg 1 MG 5.737 20% - - - - -
J9296 - Injection, pemetrexed (accord), not therapeutically equivalent to j9305, 10 mg 10 MG 9.656 20% - - - - -
J9297 - Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg 10 MG 1.731 20% - - - - -
J9298 - Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg 3 mg/1 mg 183.63 20% - - - - -
J9299 - Injection, nivolumab, 1 mg 1 MG 30.457 20% - - - - -
J9301 - Injection, obinutuzumab, 10 mg 10 MG 70.546 20% - - - - -
J9303 - Injection, panitumumab, 10 mg 10 MG 149.709 19.646% - - - - -
J9304 - Injection, pemetrexed (pemfexy), 10 mg 10 MG 64.476 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