ASP Drug Pricing - (4th Quarter)
October 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2023 (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 10 * Effective October 1, 2023 - December 31, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J1805 - Injection, esmolol hydrochloride, 10 mg 10 MG 0.245 20% - - - - -
J1806 - Injection, esmolol hydrochloride (wg critical care), not therapeutically equivalent to j1805, 10 mg 10 MG 0.469 20% - - - - -
J1811 - Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 6.673 20% - - - - -
J1813 - Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 15.675 20% - - - - -
J1817 - Insulin for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 8.302 20% - - - - -
J1823 - Injection, inebilizumab-cdon, 1 mg 1 MG 473.513 20% - - - - -
J1836 - Injection, metronidazole, 10 mg 10 MG 0.024 20% - - - - -
J1885 - Injection, ketorolac tromethamine, per 15 mg 15 MG 0.605351153733696 20% - - - - -
J1920 - Injection, labetalol hydrochloride, 5 mg 5 MG 0.183194989926029 20% - - - - -
J1921 - Injection, labetalol hydrochloride (hikma), not therapeutically equivalent to j1920, 5 mg 5 MG 2.721 20% - - - - -
J1930 - Injection, lanreotide, 1 mg 1 MG 51.156 20% - - - - -
J1931 - Injection, laronidase, 0.1 mg 0.1 MG 37.438 20% - - - - -
J1932 - Injection, lanreotide, (cipla), 1 mg 1 MG 49.971 20% - - - - -
J1940 - Injection, furosemide, up to 20 mg 20 MG 0.582 20% - - - - -
J1943 - Injection, aripiprazole lauroxil, (aristada initio), 1 mg 1 MG 3.053 20% - - - - -
J1944 - Injection, aripiprazole lauroxil, (aristada), 1 mg 1 MG 3.105 20% - - - - -
J1950 - Injection, leuprolide acetate (for depot suspension), per 3.75 mg 3.75 MG 1524.336 19.8947932513346% - - - - -
J1951 - Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg 0.25 MG 133.639 20% - - - - -
J1952 - Leuprolide injectable, camcevi, 1 mg 1 mg 74.349 20% - - - - -
J1953 - Injection, levetiracetam, 10 mg 10 MG 0.065 20% - - - - -
J1954 - Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg 7.5 MG 362.053 20% - - - - -
J1955 - Injection, levocarnitine, per 1 gm 1 GM 35.438 20% - - - - -
J1956 - Injection, levofloxacin, 250 mg 250 MG 0.928 20% - - - - -
J1961 - Injection, lenacapavir (only for use as hiv treatment), 1 mg 1 MG 21.793 20% - - - - -
J1980 - Injection, hyoscyamine sulfate, up to 0.25 mg 0.25 MG 35.464 20% - - - - -
* Effective October 1, 2023 - December 31, 2023

Drugs not otherwise classified - October 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2023 - December 31, 2023

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.287
Aztreonam 500 MG 14.712
Bumetanide 0.25 MG 0.391
Carmustine (Accord) 100 MG 594.083
Diltiazem Hydrochloride 5 MG 0.342
Doxycycline Hyclate 100 MG 15.616
Famotidine 10 MG 0.408
Flumazenil 0.1 MG 0.795
Folic Acid 5 MG 2.905
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.345 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 4.884 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.14171822859631
Rifampin 600 MG 84.394
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.692
Sulfamethoxazole-Trimethoprim 400-80 MG 0.636

ASP (Average Sale Price) Drug Pricing History