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 30 * 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
Q5105 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units 100 UNITS 0.75 20% - - - - -
Q5106 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units 1000 UNITS 7.495 20% - - - - -
Q5107 - Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg 10 MG 28.398 20% - - - - -
Q5108 - Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg 0.5 MG 111.145 20% - - - - -
Q5110 - Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram 1 MCG 0.326 20% - - - - -
Q5111 - Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg 0.5 MG 124.782 20% - - - - -
Q5112 - Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg 10 MG 46.927 20% - - - - -
Q5113 - Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg 10 MG 29.87 20% - - - - -
Q5114 - Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg 10 MG 40.405 20% - - - - -
Q5115 - Injection, rituximab-abbs, biosimilar, (truxima), 10 mg 10 MG 39.791 20% - - - - -
Q5116 - Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg 10 MG 23.154 20% - - - - -
Q5117 - Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg 10 MG 23.96 20% - - - - -
Q5118 - Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg 10 MG 28.191 20% - - - - -
Q5119 - Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg 10 MG 27.509 20% - - - - -
Q5120 - Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mg 0.5 MG 30.049 20% - - - - -
Q5121 - Injection, infliximab-axxq, biosimilar, (avsola), 10 mg 10 MG 28.334 20% - - - - -
Q5122 - Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg 0.5 MG 101.891 20% - - - - -
Q5123 - Injection, rituximab-arrx, biosimilar, (riabni), 10 mg 10 MG 44.579 20% - - - - -
Q5124 - Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg 0.1 MG 220.828 20% - - - - -
Q5125 - Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram 1 MCG 0.586 20% - - - - -
Q5126 - Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg 10 MG 72.518 20% - - - - -
Q5128 - Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg 0.1 MG 279.498 20% - - - - -
Q9950 - Injection, sulfur hexafluoride lipid microspheres, per ml 1 ML 18.997 20% - - - - -
Q9956 - Injection, octafluoropropane microspheres, per ml 1 ML 42.72 20% - - - - -
Q9957 - Injection, perflutren lipid microspheres, per ml 1 ML 42.72 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