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 9 * 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
J1571 - Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml 0.5 ML 66.257 20% - - - - -
J1572 - Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 56.116 14.15% - - - - -
J1575 - Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin 100 MG 16.655 20% - - - - -
J1576 - Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 65.741 20% - - - - -
J1580 - Injection, garamycin, gentamicin, up to 80 mg 80 MG 2.992 20% - - - - -
J1602 - Injection, golimumab, 1 mg, for intravenous use 1 MG 13.287 20% - - - - -
J1610 - Injection, glucagon hydrochloride, per 1 mg 1 MG 195.175 20% - - - - -
J1611 - Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg 1 MG 101.412 20% - - - - -
J1626 - Injection, granisetron hydrochloride, 100 mcg 100 MCG 0.389 20% - - - - -
J1627 - Injection, granisetron, extended-release, 0.1 mg 0.1 MG 5.877 20% - - - - -
J1630 - Injection, haloperidol, up to 5 mg 5 MG 1.383 20% - - - - -
J1631 - Injection, haloperidol decanoate, per 50 mg 50 MG 8.325 20% - - - - -
J1640 - Injection, hemin, 1 mg 1 MG 31.081 19.461% - - - - -
J1642 - Injection, heparin sodium, (heparin lock flush), per 10 units 10 UNITS 0.069 20% - - - - -
J1643 - Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units 1000 UNITS 6.094 20% - - - - -
J1644 - Injection, heparin sodium, per 1000 units 1000 UNITS 0.263 20% - - - - -
J1645 - Injection, dalteparin sodium, per 2500 iu 2500 IU 16.601 11.892% - - - - -
J1650 - Injection, enoxaparin sodium, 10 mg 10 MG 0.677 20% - - - - -
J1652 - Injection, fondaparinux sodium, 0.5 mg 0.5 MG 1.071 20% - - - - -
J1670 - Injection, tetanus immune globulin, human, up to 250 units 250 UNITS 540.989 20% - - - - -
J1720 - Injection, hydrocortisone sodium succinate, up to 100 mg 100 MG 17.514 20% - - - - -
J1738 - Injection, meloxicam, 1 mg 1 MG 3.321 20% - - - - -
J1740 - Injection, ibandronate sodium, 1 mg 1 MG 29.314 20% - - - - -
J1743 - Injection, idursulfase, 1 mg 1 MG 542.918 20% - - - - -
J1745 - Injection, infliximab, excludes biosimilar, 10 mg 10 MG 32.907 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