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 20 * 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
J7614 - Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 0.5 mg 0.5 MG 0.05 20% - - - - -
J7620 - Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, fda-approved final product, non-compounded, administered through dme 2.5 MG/0.5 MG 0.153 20% - - - - -
J7626 - Budesonide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 0.5 mg 0.5 MG 1.148 20% - - - - -
J7631 - Cromolyn sodium, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 10 milligrams 10 MG 1.311 20% - - - - -
J7639 - Dornase alfa, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1 MG 52.254 20% - - - - -
J7644 - Ipratropium bromide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1 MG 0.318 20% - - - - -
J7674 - Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg 1 MG 0.863 20% - - - - -
J7677 - Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through dme, 1 microgram 1 MCG 0.189 20% - - - - -
J7682 - Tobramycin, inhalation solution, fda-approved final product, non-compounded, unit dose form, administered through dme, per 300 milligrams 300 MG 24.076 20% - - - - -
J7686 - Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg 1.74 MG 733.638 20% - - - - -
J8501 - Aprepitant, oral, 5 mg 5 MG 3.458 20% - - - - -
J8520 - Capecitabine, oral, 150 mg 150 MG 0.291 20% - - - - -
J8521 - Capecitabine, oral, 500 mg 500 MG 1.169 20% - - - - -
J8530 - Cyclophosphamide; oral, 25 mg 25 MG 1.006 20% - - - - -
J8540 - Dexamethasone, oral, 0.25 mg 0.25 MG 0.078 20% - - - - -
J8560 - Etoposide; oral, 50 mg 50 MG 76.534 20% - - - - -
J8610 - Methotrexate; oral, 2.5 mg 2.5 MG 0.255 20% - - - - -
J8655 - Netupitant 300 mg and palonosetron 0.5 mg, oral 0.5 MG 407.833 17.9955992171854% - - - - -
J8670 - Rolapitant, oral, 1 mg 1 MG 1.731 20% - - - - -
J8700 - Temozolomide, oral, 5 mg 5 MG 0.187 20% - - - - -
J8705 - Topotecan, oral, 0.25 mg 0.25 mg 113.779 20% - - - - -
J9000 - Injection, doxorubicin hydrochloride, 10 mg 10 MG 2.684 20% - - - - -
J9017 - Injection, arsenic trioxide, 1 mg 1 MG 18.499 20% - - - - -
J9021 - Injection, asparaginase, recombinant, (rylaze), 0.1 mg 0.1 MG 49.714 20% - - - - -
J9022 - Injection, atezolizumab, 10 mg 10 MG 82.622 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