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 18 * 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
J7210 - Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u. 1 IU 1.448 20% - - - - -
J7211 - Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u. 1 IU 1.425 20% - - - - -
J7212 - Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram 1 MCG 2.022 20% - - - - -
J7213 - Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. 1 IU 1.764 20% - - - - -
J7214 - Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii i.u. 1 IU 4.733 20% - - - - -
J7308 - Aminolevulinic acid hcl for topical administration, 20%, single unit dosage form (354 mg) 354 MG 390.561 20% - - - - -
J7311 - Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01 mg 0.01 MG 341.4 20% - - - - -
J7312 - Injection, dexamethasone, intravitreal implant, 0.1 mg 0.1 MG 205.685 20% - - - - -
J7313 - Injection, fluocinolone acetonide, intravitreal implant (iluvien), 0.01 mg 0.01 MG 490.947 20% - - - - -
J7314 - Injection, fluocinolone acetonide, intravitreal implant (yutiq), 0.01 mg 0.01 MG 529.062 20% - - - - -
J7318 - Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg 1 MG 6.271 20% - - - - -
J7320 - Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg 1 MG 5.775 20% - - - - -
J7321 - Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose per dose 75.766 20% - - - - -
J7322 - Hyaluronan or derivative, hymovis or hymovis one, for intra-articular injection, 1 mg 1 MG 17.295 20% - - - - -
J7323 - Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose per dose 123.142 20% - - - - -
J7324 - Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose PER DOSE 136.255 20% - - - - -
J7325 - Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg 1 MG 8.77 20% - - - - -
J7326 - Hyaluronan or derivative, gel-one, for intra-articular injection, per dose per dose 515.302 20% - - - - -
J7327 - Hyaluronan or derivative, monovisc, for intra-articular injection, per dose PER DOSE 728.291 20% - - - - -
J7328 - Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg 0.1 MG 0.541 20% - - - - -
J7329 - Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg 1 MG 8.564 20% - - - - -
J7331 - Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg 1 MG 11.827 20% - - - - -
J7332 - Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg 1 MG 10.338 20% - - - - -
J7336 - Capsaicin 8% patch, per square centimeter 1 SQ CM 3.272 20% - - - - -
J7340 - Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml 100 ML 226.8 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