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 14 * 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
J2788 - Injection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.) 50 MCG (250 IU) 25.51 20% - - - - -
J2790 - Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) 300 MCG (1500 IU) 77.296 20% - - - - -
J2791 - Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu 100 IU 4.854 20% - - - - -
J2792 - Injection, rho d immune globulin, intravenous, human, solvent detergent, 100 iu 100 IU 33.457 20% - - - - -
J2794 - Injection, risperidone (risperdal consta), 0.5 mg 0.5 MG 12.148 20% - - - - -
J2795 - Injection, ropivacaine hydrochloride, 1 mg 1 MG 0.068 20% - - - - -
J2796 - Injection, romiplostim, 10 micrograms 10 MCG 95.752 19.9349716795684% - - - - -
J2798 - Injection, risperidone, (perseris), 0.5 mg 0.5 mg 11.641 20% - - - - -
J2800 - Injection, methocarbamol, up to 10 ml 10 ML 6.066 20% - - - - -
J2805 - Injection, sincalide, 5 micrograms 5 MCG 129.036 20% - - - - -
J2820 - Injection, sargramostim (gm-csf), 50 mcg 50 MCG 58.261 19.7113915630814% - - - - -
J2860 - Injection, siltuximab, 10 mg 10 MG 148.963 18.9835631764794% - - - - -
J2916 - Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg 12.5 MG 2.095 20% - - - - -
J2920 - Injection, methylprednisolone sodium succinate, up to 40 mg 40 MG 3.433 20% - - - - -
J2930 - Injection, methylprednisolone sodium succinate, up to 125 mg 125 MG 4.985 20% - - - - -
J2997 - Injection, alteplase recombinant, 1 mg 1 MG 89.161 20% - - - - -
J3000 - Injection, streptomycin, up to 1 gm 1 GM 33.368 20% - - - - -
J3010 - Injection, fentanyl citrate, 0.1 mg 0.1 MG 0.85 20% - - - - -
J3032 - Injection, eptinezumab-jjmr, 1 mg 1 MG 17.434 20% - - - - -
J3060 - Injection, taliglucerase alfa, 10 units 10 UNITS 45.175 20% - - - - -
J3090 - Injection, tedizolid phosphate, 1 mg 1 MG 1.74 20% - - - - -
J3095 - Injection, telavancin, 10 mg 10 MG 7.153 20% - - - - -
J3101 - Injection, tenecteplase, 1 mg 1 MG 153.096 20% - - - - -
J3105 - Injection, terbutaline sulfate, up to 1 mg 1 MG 14.304 20% - - - - -
J3111 - Injection, romosozumab-aqqg, 1 mg 1 MG 10.347 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