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 6 * 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
J0885 - Injection, epoetin alfa, (for non-esrd use), 1000 units 1000 UNITS 6.876 20% - - - - -
J0887 - Injection, epoetin beta, 1 microgram, (for esrd on dialysis) 1 MCG 1.647 20% - - - - -
J0888 - Injection, epoetin beta, 1 microgram, (for non esrd use) 1 MCG 1.647 20% - - - - -
J0891 - Injection, argatroban (accord), not therapeutically equivalent to j0883, 1 mg (for non-esrd use) 1 MG 0.46 20% - - - - -
J0892 - Injection, argatroban (accord), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis) 1 MG 0.46 20% - - - - -
J0893 - Injection, decitabine (sun pharma), not therapeutically equivalent to j0894, 1 mg 1 MG 2.24 20% - - - - -
J0894 - Injection, decitabine, 1 mg 1 MG 2 20% - - - - -
J0895 - Injection, deferoxamine mesylate, 500 mg 500 MG 8.592 20% - - - - -
J0896 - Injection, luspatercept-aamt, 0.25 mg 0.25 MG 39.181 20% - - - - -
J0897 - Injection, denosumab, 1 mg 1 MG 24.192 19.829% - - - - -
J0898 - Injection, argatroban (auromedics), not therapeutically equivalent to j0883, 1 mg (for non-esrd use) 1 MG 1.642 20% - - - - -
J0899 - Injection, argatroban (auromedics), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis) 1 MG 1.642 20% - - - - -
J1000 - Injection, depo-estradiol cypionate, up to 5 mg 5 MG 30.682 20% - - - - -
J1020 - Injection, methylprednisolone acetate, 20 mg 20 MG 7.167 20% - - - - -
J1030 - Injection, methylprednisolone acetate, 40 mg 40 MG 7.613 20% - - - - -
J1040 - Injection, methylprednisolone acetate, 80 mg 80 MG 11.91 20% - - - - -
J1071 - Injection, testosterone cypionate, 1 mg 1 MG 0.029 20% - - - - -
J1100 - Injection, dexamethasone sodium phosphate, 1 mg 1 MG 0.122 20% - - - - -
J1110 - Injection, dihydroergotamine mesylate, per 1 mg 1 MG 50.588 20% - - - - -
J1120 - Injection, acetazolamide sodium, up to 500 mg 500 MG 29.702 20% - - - - -
J1160 - Injection, digoxin, up to 0.5 mg 0.5 MG 10.814 20% - - - - -
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 4593.574 20% - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.63 20% - - - - -
J1170 - Injection, hydromorphone, up to 4 mg 4 MG 4.347 20% - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 113.897 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