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 19 * 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
J7345 - Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg 10 MG 1.66 20% - - - - -
J7351 - Injection, bimatoprost, intracameral implant, 1 microgram 1 MCG 206.225 20% - - - - -
J7402 - Mometasone furoate sinus implant, (sinuva), 10 micrograms 10 MCG 11.345 20% - - - - -
J7500 - Azathioprine, oral, 50 mg 50 MG 11.752 20% - - - - -
J7502 - Cyclosporine, oral, 100 mg 100 MG 2.207 20% - - - - -
J7503 - Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg 0.25 MG 1.675 20% - - - - -
J7504 - Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg 250 MG 3254.873 16.8337324697173% - - - - -
J7507 - Tacrolimus, immediate release, oral, 1 mg 1 MG 0.3 20% - - - - -
J7508 - Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg 0.1 MG 0.553 20% - - - - -
J7509 - Methylprednisolone oral, per 4 mg 4 MG 0.241 20% - - - - -
J7510 - Prednisolone oral, per 5 mg 5 MG 0.241 20% - - - - -
J7511 - Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg 25 MG 921.169 20% - - - - -
J7512 - Prednisone, immediate release or delayed release, oral, 1 mg 1 MG 0.008 20% - - - - -
J7515 - Cyclosporine, oral, 25 mg 25 MG 0.685 20% - - - - -
J7517 - Mycophenolate mofetil, oral, 250 mg 250 MG 0.198 20% - - - - -
J7518 - Mycophenolic acid, oral, 180 mg 180 MG 0.873 20% - - - - -
J7520 - Sirolimus, oral, 1 mg 1 MG 3.155 20% - - - - -
J7525 - Tacrolimus, parenteral, 5 mg 5 MG 248.745 20% - - - - -
J7527 - Everolimus, oral, 0.25 mg 0.25 MG 2.866 20% - - - - -
J7605 - Arformoterol, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 15 micrograms 15 mcg 2.648 20% - - - - -
J7606 - Formoterol fumarate, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 20 micrograms 20 MCG 4.879 20% - - - - -
J7608 - Acetylcysteine, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per gram 1 GM 9.874 20% - - - - -
J7611 - Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 1 mg 1 MG 0.124 20% - - - - -
J7612 - Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 0.5 mg 0.5 MG 0.225 20% - - - - -
J7613 - Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 1 mg 1 MG 0.042 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