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 13 * 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
J2540 - Injection, penicillin g potassium, up to 600,000 units 600000 UNITS 0.817 20% - - - - -
J2543 - Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 1.125 GM 0.886 20% - - - - -
J2545 - Pentamidine isethionate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 300 mg 300 MG 92.416 20% - - - - -
J2550 - Injection, promethazine hcl, up to 50 mg 50 MG 3.479 20% - - - - -
J2560 - Injection, phenobarbital sodium, up to 120 mg 120 MG 36.252 20% - - - - -
J2562 - Injection, plerixafor, 1 mg 1 MG 429.053 20% - - - - -
J2597 - Injection, desmopressin acetate, per 1 mcg 1 MCG 6.145 20% - - - - -
J2598 - Injection, vasopressin, 1 unit 1 UNIT 2.555 20% - - - - -
J2599 - Injection, vasopressin (american regent), not therapeutically equivalent to j2598, 1 unit 1 UNIT 0.561 20% - - - - -
J2675 - Injection, progesterone, per 50 mg 50 MG 0.888 20% - - - - -
J2680 - Injection, fluphenazine decanoate, up to 25 mg 25 MG 9.873 20% - - - - -
J2690 - Injection, procainamide hcl, up to 1 gm 1 GM 340.441 20% - - - - -
J2700 - Injection, oxacillin sodium, up to 250 mg 250 MG 0.974 20% - - - - -
J2704 - Injection, propofol, 10 mg 10 MG 0.0962252681247808 20% - - - - -
J2720 - Injection, protamine sulfate, per 10 mg 10 MG 0.79263032 20% - - - - -
J2724 - Injection, protein c concentrate, intravenous, human, 10 iu 10 UNITS 15.135 20% - - - - -
J2760 - Injection, phentolamine mesylate, up to 5 mg 5 MG 453.659 20% - - - - -
J2765 - Injection, metoclopramide hcl, up to 10 mg 10 MG 1.108 20% - - - - -
J2777 - Injection, faricimab-svoa, 0.1 mg 0.1 MG 36.573 20% - - - - -
J2778 - Injection, ranibizumab, 0.1 mg 0.1 mg 197.372 20% - - - - -
J2779 - Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg 0.1 MG 81.432 20% - - - - -
J2781 - Injection, pegcetacoplan, intravitreal, 1 mg 1 MG 153.521 20% - - - - -
J2783 - Injection, rasburicase, 0.5 mg 0.5 MG 358.429 20% - - - - -
J2785 - Injection, regadenoson, 0.1 mg 0.1 MG 34.762 20% - - - - -
J2786 - Injection, reslizumab, 1 mg 1 MG 10.301 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