ASP Drug Pricing - (4th Quarter)
October 2022
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2022 (2nd 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 12 * Effective October 1, 2022 - December 31, 2022
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J2783 - Injection, rasburicase, 0.5 mg 0.5 MG 332.079 - - - - - -
J2785 - Injection, regadenoson, 0.1 mg 0.1 MG 61.345 - - - - - -
J2786 - Injection, reslizumab, 1 mg 1 MG 10.106 - - - - - -
J2788 - Injection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.) 50 MCG (250 IU) 23.193 - - - - - -
J2790 - Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) 300 MCG (1500 IU) 80.405 - - - - - -
J2791 - Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu 100 IU 4.706 - - - - - -
J2792 - Injection, rho d immune globulin, intravenous, human, solvent detergent, 100 iu 100 IU 32.45 - - - - - -
J2794 - Injection, risperidone (risperdal consta), 0.5 mg 0.5 MG 11.586 - - - - - -
J2795 - Injection, ropivacaine hydrochloride, 1 mg 1 MG 0.092 - - - - - -
J2796 - Injection, romiplostim, 10 micrograms 10 MCG 88.996 - - - - - -
J2798 - Injection, risperidone, (perseris), 0.5 mg 0.5 mg 11.163 - - - - - -
J2800 - Injection, methocarbamol, up to 10 ml 10 ML 7.225 - - - - - -
J2805 - Injection, sincalide, 5 micrograms 5 MCG 123.162 - - - - - -
J2820 - Injection, sargramostim (gm-csf), 50 mcg 50 MCG 55.443 - - - - - -
J2860 - Injection, siltuximab, 10 mg 10 MG 132.004 - - - - - -
J2916 - Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg 12.5 MG 1.945 - - - - - -
J2920 - Injection, methylprednisolone sodium succinate, up to 40 mg 40 MG 4.277 - - - - - -
J2930 - Injection, methylprednisolone sodium succinate, up to 125 mg 125 MG 5.742 - - - - - -
J2997 - Injection, alteplase recombinant, 1 mg 1 MG 88.031 - - - - - -
J3000 - Injection, streptomycin, up to 1 gm 1 GM 39.862 - - - - - -
J3010 - Injection, fentanyl citrate, 0.1 mg 0.1 MG 0.894 - - - - - -
J3032 - Injection, eptinezumab-jjmr, 1 mg 1 MG 16.411 - - - - - -
J3060 - Injection, taliglucerase alfa, 10 units 10 UNITS 41.903 - - - - - -
J3090 - Injection, tedizolid phosphate, 1 mg 1 MG 1.744 - - - - - -
J3095 - Injection, telavancin, 10 mg 10 MG 6.691 - - - - - -
* Effective October 1, 2022 - December 31, 2022

Drugs not otherwise classified - October 2022

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2022 - December 31, 2022

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.162
Allopurinol Sodium 500 MG 2889.811
Aminocaproic acid 250 MG 0.329
Aztreonam 500 MG 14.801
Bortezomib (Dr. Reddy's) 0.1 MG 17.974
Bumetanide 0.25 MG 0.35
Bupivacaine 1 ML 0.123
Clindamycin Phosphate 150 MG 1.018
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.826 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.307
Doxycycline Hyclate 100 MG 17.103
Esmolol Hydrochloride 10 MG 0.299
Famotidine 10 MG 0.346
Flumazenil 0.1 MG 0.938
Folic Acid 5 MG 3.289
Glucarpidase 10 UNITS 362.572
Glycopyrrolate injection 0.2 MG 1.982
Immune Globulin (Panzyga) 500 MG 69.638
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 Units 8.461 Added October 2022
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 Units 15.871 Added October 2022
Labetalol Hcl 5 MG 0.186
Metoprolol Tartrate 1 MG 0.152
Metronidazole inj 500 MG 1.401
Nitroglycerin 5 MG 1.362
Olanzapine short acting intramuscular injection 0.5 MG 1.042
Paliperidone Palmitate (Invega Trinza) 1 MG 11.288
Rifampin 600 MG 95.198
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.373
Sulfamethoxazole-Trimethoprim 400-80 MG 0.669
Vasopressin 20 UNITS 172.139
Vasopressin (American Regent) 20 UNITS 136.351 Added October 2022

ASP (Average Sale Price) Drug Pricing History