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 8 * 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
J1439 - Injection, ferric carboxymaltose, 1 mg 1 MG 1.125 20% - - - - -
J1442 - Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram 1 MCG 0.985 20% - - - - -
J1447 - Injection, tbo-filgrastim, 1 microgram 1 MCG 0.426 20% - - - - -
J1448 - Injection, trilaciclib, 1mg 1 MG 5.102 20% - - - - -
J1449 - Injection, eflapegrastim-xnst, 0.1 mg 0.1 MG 31.771 20% - - - - -
J1450 - Injection fluconazole, 200 mg 200 MG 2.68 20% - - - - -
J1453 - Injection, fosaprepitant, 1 mg 1 MG 0.142 20% - - - - -
J1454 - Injection, fosnetupitant 235 mg and palonosetron 0.25 mg 0.25 MG 371.999 20% - - - - -
J1456 - Injection, fosaprepitant (teva), not therapeutically equivalent to j1453, 1 mg 1 MG 0.098 20% - - - - -
J1458 - Injection, galsulfase, 1 mg 1 MG 461.919 20% - - - - -
J1459 - Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 47.992 20% - - - - -
J1460 - Injection, gamma globulin, intramuscular, 1 cc 1 CC 48.465 20% - - - - -
J1551 - Injection, immune globulin (cutaquig), 100 mg 100 MG 14.386 20% - - - - -
J1554 - Injection, immune globulin (asceniv), 500 mg 500 MG 491.405 20% - - - - -
J1555 - Injection, immune globulin (cuvitru), 100 mg 100 MG 16.275 19.97% - - - - -
J1556 - Injection, immune globulin (bivigam), 500 mg 500 MG 72.963 20% - - - - -
J1557 - Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 59.483 19.155% - - - - -
J1558 - Injection, immune globulin (xembify), 100 mg 100 MG 13.999 20% - - - - -
J1559 - Injection, immune globulin (hizentra), 100 mg 100 MG 12.803 20% - - - - -
J1560 - Injection, gamma globulin, intramuscular, over 10 cc 10 CC 484.648 20% - - - - -
J1561 - Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg 500 MG 50.64 20% - - - - -
J1566 - Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg 500 MG 77.766 19.38% - - - - -
J1568 - Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 44.118 20% - - - - -
J1569 - Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg 500 MG 46.031 20% - - - - -
J1570 - Injection, ganciclovir sodium, 500 mg 500 MG 39.494 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