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 22 * 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
J9065 - Injection, cladribine, per 1 mg 1 MG 16.757 20% - - - - -
J9070 - Cyclophosphamide, 100 mg 100 MG 17.942 20% - - - - -
J9071 - Injection, cyclophosphamide (auromedics), 5 mg 5 MG 3.869 20% - - - - -
J9100 - Injection, cytarabine, 100 mg 100 MG 0.941 20% - - - - -
J9118 - Injection, calaspargase pegol-mknl, 10 units 10 UNIT 72.883 20% - - - - -
J9119 - Injection, cemiplimab-rwlc, 1 mg 1 MG 26.921 20% - - - - -
J9120 - Injection, dactinomycin, 0.5 mg 0.5 MG 838.464 20% - - - - -
J9130 - Dacarbazine, 100 mg 100 MG 3.761 20% - - - - -
J9144 - Injection, daratumumab, 10 mg and hyaluronidase-fihj 10 MG 49.31 20% - - - - -
J9145 - Injection, daratumumab, 10 mg 10 MG 62.134 20% - - - - -
J9150 - Injection, daunorubicin, 10 mg 10 MG 31.636 20% - - - - -
J9153 - Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine 1 MG/2.27 MG 227.936 20% - - - - -
J9155 - Injection, degarelix, 1 mg 1 MG 4.127 20% - - - - -
J9171 - Injection, docetaxel, 1 mg 1 MG 0.804 20% - - - - -
J9173 - Injection, durvalumab, 10 mg 10 MG 79.741 20% - - - - -
J9176 - Injection, elotuzumab, 1 mg 1 MG 7.218 20% - - - - -
J9177 - Injection, enfortumab vedotin-ejfv, 0.25 mg 0.25 MG 35.057 19.228723008916% - - - - -
J9178 - Injection, epirubicin hcl, 2 mg 2 MG 1.446 20% - - - - -
J9179 - Injection, eribulin mesylate, 0.1 mg 0.1 MG 130.874 20% - - - - -
J9181 - Injection, etoposide, 10 mg 10 MG 0.766 20% - - - - -
J9185 - Injection, fludarabine phosphate, 50 mg 50 MG 500.459 20% - - - - -
J9190 - Injection, fluorouracil, 500 mg 500 MG 2.838 20% - - - - -
J9196 - Injection, gemcitabine hydrochloride (accord), not therapeutically equivalent to j9201, 200 mg 200 MG 3.689 20% - - - - -
J9198 - Injection, gemcitabine hydrochloride, (infugem), 100 mg 100 MG 40.28 19.6686706427487% - - - - -
J9200 - Injection, floxuridine, 500 mg 500 MG 3551 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