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 25 * 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
J9305 - Injection, pemetrexed, not otherwise specified, 10 mg 10 MG 7.933 20% - - - - -
J9306 - Injection, pertuzumab, 1 mg 1 MG 15.366 20% - - - - -
J9307 - Injection, pralatrexate, 1 mg 1 MG 356.512 19.902% - - - - -
J9308 - Injection, ramucirumab, 5 mg 5 MG 68.87 20% - - - - -
J9309 - Injection, polatuzumab vedotin-piiq, 1 mg 1 MG 121.252 20% - - - - -
J9311 - Injection, rituximab 10 mg and hyaluronidase 10 mg 37.458 20% - - - - -
J9312 - Injection, rituximab, 10 mg 10 MG 81.037 20% - - - - -
J9313 - Injection, moxetumomab pasudotox-tdfk, 0.01 mg 0.01 MG 23.394 20% - - - - -
J9314 - Injection, pemetrexed (teva), not therapeutically equivalent to j9305, 10 mg 10 MG 12.3 20% - - - - -
J9316 - Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg 10 MG 68.21 20% - - - - -
J9317 - Injection, sacituzumab govitecan-hziy, 2.5 mg 2.5 MG 33.315 20% - - - - -
J9319 - Injection, romidepsin, lyophilized, 0.1 mg 0.1 MG 30.37 20% - - - - -
J9320 - Injection, streptozocin, 1 gram 1 GM 370.184 20% - - - - -
J9325 - Injection, talimogene laherparepvec, per 1 million plaque forming units 1 million PFU 66.054 19.57% - - - - -
J9328 - Injection, temozolomide, 1 mg 1 MG 10.41 20% - - - - -
J9330 - Injection, temsirolimus, 1 mg 1 MG 33.637 20% - - - - -
J9331 - Injection, sirolimus protein-bound particles, 1 mg 1 MG 107.606 20% - - - - -
J9332 - Injection, efgartigimod alfa-fcab, 2mg 2 MG 31.811 20% - - - - -
J9340 - Injection, thiotepa, 15 mg 15 MG 259.563 20% - - - - -
J9347 - Injection, tremelimumab-actl, 1 mg 1 MG 136.56 20% - - - - -
J9348 - Injection, naxitamab-gqgk, 1 mg 1 MG 579.649 20% - - - - -
J9349 - Injection, tafasitamab-cxix, 2 mg 2 MG 13.302 20% - - - - -
J9351 - Injection, topotecan, 0.1 mg 0.1 MG 0.499 20% - - - - -
J9352 - Injection, trabectedin, 0.1 mg 0.1 MG 337.279 20% - - - - -
J9353 - Injection, margetuximab-cmkb, 5 mg 5 MG 45.881 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