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 26 * 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
J9354 - Injection, ado-trastuzumab emtansine, 1 mg 1 MG 38.325 20% - - - - -
J9355 - Injection, trastuzumab, excludes biosimilar, 10 mg 10 MG 81.079 20% - - - - -
J9356 - Injection, trastuzumab, 10 mg and hyaluronidase-oysk 10 MG 65.583 20% - - - - -
J9357 - Injection, valrubicin, intravesical, 200 mg 200 MG 1391.799 20% - - - - -
J9358 - Injection, fam-trastuzumab deruxtecan-nxki, 1 mg 1 MG 26.235 20% - - - - -
J9359 - Injection, loncastuximab tesirine-lpyl, 0.075 mg 0.075 MG 196.449 20% - - - - -
J9360 - Injection, vinblastine sulfate, 1 mg 1 MG 3.952 20% - - - - -
J9370 - Vincristine sulfate, 1 mg 1 MG 7.486 20% - - - - -
J9380 - Injection, teclistamab-cqyv, 0.5 mg 0.5 MG 30.935 20% - - - - -
J9381 - Injection, teplizumab-mzwv, 5 mcg 5 MCG 36.273 20% - - - - -
J9390 - Injection, vinorelbine tartrate, 10 mg 10 MG 8.268 20% - - - - -
J9393 - Injection, fulvestrant (teva), not therapeutically equivalent to j9395, 25 mg 25 MG 21.2 20% - - - - -
J9394 - Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg 25 MG 1.653 20% - - - - -
J9395 - Injection, fulvestrant, 25 mg 25 MG 9.47 20% - - - - -
J9400 - Injection, ziv-aflibercept, 1 mg 1 MG 6.812 20% - - - - -
P9041 - Infusion, albumin (human), 5%, 50 ml 50 ML 10.615 20% - - - - 95 10.615
P9045 - Infusion, albumin (human), 5%, 250 ml 250 ML 53.077 20% - - - - 95 53.077
P9046 - Infusion, albumin (human), 25%, 20 ml 20 ML 21.231 20% - - - - 95 21.231
P9047 - Infusion, albumin (human), 25%, 50 ml 50 ML 53.077 20% - - - - 95 53.077
Q0138 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) 1 MG 0.503 20% - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.503 20% - - - - -
Q0162 - Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 1 MG 0.014 20% - - - - -
Q0167 - Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 2.5 MG 0.733 20% - - - - -
Q2041 - Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION CAR T CELLS 449440 20% - - - - -
Q2043 - Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion Per infusion (minimum 50 million cells) 53062.441 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