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 3 * 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
J0456 - Injection, azithromycin, 500 mg 500 MG 2.778 20% - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.089 20% - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 182.487 20% - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 44.966 20% - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4389.082 20% - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.781 20% - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 50.927 20% - - - - -
J0491 - Injection, anifrolumab-fnia, 1 mg 1 MG 16.656 20% - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 25.436 20% - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 16.211 20% - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 170.925 20% - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 15.673 17.573% - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 20.168 17.233% - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.853 20% - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 0.238 20% - - - - -
J0584 - Injection, burosumab-twza 1 mg 1 MG 426.072 19.812% - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 6.394 20% - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.246 20% - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 12.721 20% - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.196 20% - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 4.063 20% - - - - -
J0594 - injection, busulfan, 1 mg 1 MG 1.383 20% - - - - -
J0595 - Injection, butorphanol tartrate, 1 mg 1 MG 5.049 20% - - - - -
J0596 - Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units 10 UNITS 33.02 20% - - - - -
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 64.445 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