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 11 * 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
J2001 - Injection, lidocaine hcl for intravenous infusion, 10 mg 10 MG 0.026 20% - - - - -
J2010 - Injection, lincomycin hcl, up to 300 mg 300 MG 11.041 20% - - - - -
J2020 - Injection, linezolid, 200 mg 200 MG 3.648 20% - - - - -
J2021 - Injection, linezolid (hospira), not therapeutically equivalent to j2020, 200 mg 200 MG 13.736 20% - - - - -
J2060 - Injection, lorazepam, 2 mg 2 MG 1.01 20% - - - - -
J2150 - Injection, mannitol, 25% in 50 ml 50 ML 5.26 20% - - - - -
J2175 - Injection, meperidine hydrochloride, per 100 mg 100 MG 6.746 20% - - - - -
J2182 - Injection, mepolizumab, 1 mg 1 MG 30.166 20% - - - - -
J2184 - Injection, meropenem (b. braun), not therapeutically equivalent to j2185, 100 mg 100 MG 2.1 20% - - - - -
J2185 - Injection, meropenem, 100 mg 100 MG 0.562455572432289 20% - - - - -
J2210 - Injection, methylergonovine maleate, up to 0.2 mg 0.2 MG 21.086 20% - - - - -
J2247 - Injection, micafungin sodium (par pharm) not thereapeutically equivalent to j2248, 1 mg 1 MG 0.395 20% - - - - -
J2248 - Injection, micafungin sodium, 1 mg 1 MG 0.749 20% - - - - -
J2250 - Injection, midazolam hydrochloride, per 1 mg 1 MG 0.166 20% - - - - -
J2251 - Injection, midazolam in 0.9% sodium chloride, intravenous, not therapeutically equivalent to j2250, 1 mg 1 MG 0.292 20% - - - - -
J2260 - Injection, milrinone lactate, 5 mg 5 MG 1.77 20% - - - - -
J2270 - Injection, morphine sulfate, up to 10 mg 10 MG 4.316 20% - - - - -
J2272 - Injection, morphine sulfate (fresenius kabi), not therapeutically equivalent to j2270, up to 10 mg 10 MG 7.071 20% - - - - -
J2274 - Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 10 MG 11.19 20% - - - - -
J2278 - Injection, ziconotide, 1 microgram 1 MCG 9.036 20% - - - - -
J2280 - Injection, moxifloxacin, 100 mg 100 MG 9.759 20% - - - - -
J2281 - Injection, moxifloxacin (fresenius kabi), not therapeutically equivalent to j2280, 100 mg 100 MG 5.31492875 20% - - - - -
J2300 - Injection, nalbuphine hydrochloride, per 10 mg 10 MG 2.873 20% - - - - -
J2305 - Injection, nitroglycerin, 5 mg 5 MG 1.294 20% - - - - -
J2310 - Injection, naloxone hydrochloride, per 1 mg 1 MG 9.541 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