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 15 * 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
J3121 - Injection, testosterone enanthate, 1 mg 1 MG 0.046 20% - - - - -
J3145 - Injection, testosterone undecanoate, 1 mg 1 MG 1.7352668324 20% - - - - -
J3230 - Injection, chlorpromazine hcl, up to 50 mg 50 MG 31.784 20% - - - - -
J3240 - Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial 0.9 MG 2011.265 20% - - - - -
J3241 - Injection, teprotumumab-trbw, 10 mg 10 MG 327.998 20% - - - - -
J3243 - Injection, tigecycline, 1 mg 1 MG 0.617 20% - - - - -
J3245 - Injection, tildrakizumab, 1 mg 1 MG 142.222 20% - - - - -
J3246 - Injection, tirofiban hcl, 0.25 mg 0.25 MG 4.405 19.698% - - - - -
J3250 - Injection, trimethobenzamide hcl, up to 200 mg 200 MG 44.945 20% - - - - -
J3260 - Injection, tobramycin sulfate, up to 80 mg 80 MG 2.65073562289142 20% - - - - -
J3262 - Injection, tocilizumab, 1 mg 1 MG 6.188 20% - - - - -
J3285 - Injection, treprostinil, 1 mg 1 MG 56.005 20% - - - - -
J3299 - Injection, triamcinolone acetonide (xipere), 1 mg 1 MG 48.583 20% - - - - -
J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg 10 MG 1.156 20% - - - - -
J3304 - Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg 1 MG 17.125 20% - - - - -
J3315 - Injection, triptorelin pamoate, 3.75 mg 3.75 MG 401.745 20% - - - - -
J3357 - Ustekinumab, for subcutaneous injection, 1 mg 1 MG 151.458 20% - - - - -
J3358 - Ustekinumab, for intravenous injection, 1 mg 1 MG 12.619 20% - - - - -
J3360 - Injection, diazepam, up to 5 mg 5 MG 7.479 20% - - - - -
J3370 - Injection, vancomycin hcl, 500 mg 500 MG 2.086 20% - - - - -
J3371 - Injection, vancomycin hcl (mylan), not therapeutically equivalent to j3370, 500 mg 500 MG 6.245 20% - - - - -
J3372 - Injection, vancomycin hcl (xellia), not therapeutically equivalent to j3370, 500 mg 500 MG 6.491 20% - - - - -
J3380 - Injection, vedolizumab, intravenous, 1 mg 1 MG 22.296 20% - - - - -
J3385 - Injection, velaglucerase alfa, 100 units 100 UNITS 366.395 20% - - - - -
J3396 - Injection, verteporfin, 0.1 mg 0.1 MG 11.237 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