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 16 * 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
J3410 - Injection, hydroxyzine hcl, up to 25 mg 25 MG 13.15 20% - - - - -
J3411 - Injection, thiamine hcl, 100 mg 100 MG 2.591 20% - - - - -
J3415 - Injection, pyridoxine hcl, 100 mg 100 MG 13.929 20% - - - - -
J3420 - Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 1000 MCG 1.325 20% - - - - -
J3430 - Injection, phytonadione (vitamin k), per 1 mg 1 MG 2.982 20% - - - - -
J3465 - Injection, voriconazole, 10 mg 10 MG 0.680042739584823 20% - - - - -
J3471 - Injection, hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 usp units) 1 UNIT 0.501 20% - - - - -
J3473 - Injection, hyaluronidase, recombinant, 1 usp unit 1 USP UNIT 0.359 20% - - - - -
J3475 - Injection, magnesium sulfate, per 500 mg 500 MG 0.761 20% - - - - -
J3480 - Injection, potassium chloride, per 2 meq 2 MEQ 0.112 20% - - - - -
J3485 - Injection, zidovudine, 10 mg 10 MG 1.511 20% - - - - -
J3486 - Injection, ziprasidone mesylate, 10 mg 10 MG 9.94501655145801 20% - - - - -
J3489 - Injection, zoledronic acid, 1 mg 1 MG 6.934 20% - - - - -
J7030 - Infusion, normal saline solution , 1000 cc 1000 ML 2.578 20% - - - - -
J7040 - Infusion, normal saline solution, sterile (500 ml = 1 unit) 500 ML 1.289 20% - - - - -
J7042 - 5% dextrose/normal saline (500 ml = 1 unit) 500 ML 1.171 20% - - - - -
J7050 - Infusion, normal saline solution, 250 cc 250 ML 0.645 20% - - - - -
J7060 - 5% dextrose/water (500 ml = 1 unit) 500 ML 1.629 20% - - - - -
J7070 - Infusion, d5w, 1000 cc 1000 CC 3.259 20% - - - - -
J7120 - Ringers lactate infusion, up to 1000 cc 1000 CC 2.448 20% - - - - -
J7170 - Injection, emicizumab-kxwh, 0.5 mg 0.5 MG 51.222 20% - - - - -
J7175 - Injection, factor x, (human), 1 i.u. 1 IU 9.112 20% - - - - -
J7177 - Injection, human fibrinogen concentrate (fibryga), 1 mg 1 MG 1.098 20% - - - - -
J7178 - Injection, human fibrinogen concentrate, not otherwise specified, 1 mg 1 IU 1.381 20% - - - - -
J7179 - Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco 1 IU 1.832 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