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 17 * 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
J7180 - Injection, factor xiii (antihemophilic factor, human), 1 i.u. 1 IU 9.673 20% - - - - -
J7181 - Injection, factor xiii a-subunit, (recombinant), per iu 1 IU 17.101 20% - - - - -
J7182 - Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu 1 IU 1.309 20% - - - - -
J7183 - Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco 1 I.U. VWF:RCO 1.298 20% - - - - -
J7185 - Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. 1 IU 1.308 20% - - - - -
J7186 - Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. PER FACTOR VIII IU 1.218 20% - - - - -
J7187 - Injection, von willebrand factor complex (humate-p), per iu vwf:rco 1 IU 1.346 20% - - - - -
J7188 - Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. 1 IU 3.221 20% - - - - -
J7189 - Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram 1 MCG 2.407 20% - - - - -
J7190 - Factor viii (antihemophilic factor, human) per i.u. 1 IU 1.188 20% - - - - -
J7192 - Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified 1 IU 1.503 20% - - - - -
J7193 - Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. 1 IU 1.32 20% - - - - -
J7194 - Factor ix, complex, per i.u. 1 IU 1.612 20% - - - - -
J7195 - Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified 1 IU 1.744 20% - - - - -
J7197 - Antithrombin iii (human), per i.u. 1 IU 3.71435613 20% - - - - -
J7198 - Anti-inhibitor, per i.u. 1 IU 2.298 20% - - - - -
J7200 - Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu 1 IU 1.603 20% - - - - -
J7201 - Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. 1 IU 3.466 20% - - - - -
J7202 - Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. 1 IU 4.931 20% - - - - -
J7203 - Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu 1 IU 4.404 20% - - - - -
J7204 - Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu 1 IU 2.055 20% - - - - -
J7205 - Injection, factor viii fc fusion protein (recombinant), per iu 1 IU 2.18 20% - - - - -
J7207 - Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. 1 IU 2.03 20% - - - - -
J7208 - Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. 1 IU 2.346 20% - - - - -
J7209 - Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. 1 IU 1.298 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