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 12 * 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
J2311 - Injection, naloxone hydrochloride (zimhi), 1 mg 1 MG 4.311 20% - - - - -
J2315 - Injection, naltrexone, depot form, 1 mg 1 MG 3.961 20% - - - - -
J2323 - Injection, natalizumab, 1 mg 1 MG 24.6 20% - - - - -
J2327 - Injection, risankizumab-rzaa, intravenous, 1 mg 1 MG 15.332 20% - - - - -
J2329 - Injection, ublituximab-xiiy, 1mg 1 MG 67.078 20% - - - - -
J2350 - Injection, ocrelizumab, 1 mg 1 MG 60.545 20% - - - - -
J2353 - Injection, octreotide, depot form for intramuscular injection, 1 mg 1 MG 207.156 20% - - - - -
J2354 - Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg 25 MCG 1.116 20% - - - - -
J2356 - Injection, tezepelumab-ekko, 1 mg 1 MG 18.58 20% - - - - -
J2357 - Injection, omalizumab, 5 mg 5 MG 39.09 20% - - - - -
J2358 - Injection, olanzapine, long-acting, 1 mg 1 MG 2.917 20% - - - - -
J2359 - Injection, olanzapine, 0.5 mg 0.5 MG 0.886 20% - - - - -
J2360 - Injection, orphenadrine citrate, up to 60 mg 60 MG 4.672 20% - - - - -
J2372 - Injection, phenylephrine hydrochloride (biorphen), 20 micrograms 20 MCG 0.181 20% - - - - -
J2401 - Injection, chloroprocaine hydrochloride, per 1 mg 1 MG 0.038 20% - - - - -
J2405 - Injection, ondansetron hydrochloride, per 1 mg 1 MG 0.0896500402348111 20% - - - - -
J2406 - Injection, oritavancin (kimyrsa), 10 mg 10 MG 40.694 20% - - - - -
J2407 - Injection, oritavancin (orbactiv), 10 mg 10 MG 27.537 20% - - - - -
J2426 - Injection, paliperidone palmitate extended release (invega sustenna), 1 mg 1 MG 14.34 20% - - - - -
J2427 - Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg 1MG 12.199 20% - - - - -
J2430 - Injection, pamidronate disodium, per 30 mg 30 MG 10.332 20% - - - - -
J2469 - Injection, palonosetron hcl, 25 mcg 25 MCG 0.884 20% - - - - -
J2501 - Injection, paricalcitol, 1 mcg 1 MCG 0.897650213151692 20% - - - - -
J2506 - Injection, pegfilgrastim, excludes biosimilar, 0.5 mg 0.5 MG 74.948 20% - - - - -
J2507 - Injection, pegloticase, 1 mg 1 MG 3307.045 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