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 23 * 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
J9201 - Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg 200 MG 3.932 20% - - - - -
J9202 - Goserelin acetate implant, per 3.6 mg 3.6 MG 611.346 20% - - - - -
J9203 - Injection, gemtuzumab ozogamicin, 0.1 mg 0.1 MG 221.843 20% - - - - -
J9204 - Injection, mogamulizumab-kpkc, 1 mg 1 MG 227.344 20% - - - - -
J9205 - Injection, irinotecan liposome, 1 mg 1 MG 62.485 20% - - - - -
J9206 - Injection, irinotecan, 20 mg 20 MG 2.064 20% - - - - -
J9207 - Injection, ixabepilone, 1 mg 1 MG 127.574 20% - - - - -
J9208 - Injection, ifosfamide, 1 gram 1 GM 25.891 20% - - - - -
J9209 - Injection, mesna, 200 mg 200 MG 1.524 20% - - - - -
J9210 - Injection, emapalumab-lzsg, 1 mg 1 MG 390.158 20% - - - - -
J9211 - Injection, idarubicin hydrochloride, 5 mg 5 MG 36.346 20% - - - - -
J9217 - Leuprolide acetate (for depot suspension), 7.5 mg 7.5 MG 166.685 20% - - - - -
J9218 - Leuprolide acetate, per 1 mg 1 MG 7.875 20% - - - - -
J9223 - Injection, lurbinectedin, 0.1 mg 0.1 MG 196.82 20% - - - - -
J9226 - Histrelin implant (supprelin la), 50 mg 50 MG 44695.101 20% - - - - -
J9227 - Injection, isatuximab-irfc, 10 mg 10 MG 74.641 20% - - - - -
J9228 - Injection, ipilimumab, 1 mg 1 MG 168.56 20% - - - - -
J9229 - Injection, inotuzumab ozogamicin, 0.1 mg 0.1 MG 2529.553 20% - - - - -
J9245 - Injection, melphalan hydrochloride, not otherwise specified, 50 mg 50 MG 176.252223484365 20% - - - - -
J9246 - Injection, melphalan (evomela), 1 mg 1 MG 16.083 20% - - - - -
J9250 - Methotrexate sodium, 5 mg 5 MG 0.233 20% - - - - -
J9259 - Injection, paclitaxel protein-bound particles (american regent), not therapeutically equivalent to j9264, 1 mg 1 MG 16.226 20% - - - - -
J9260 - Injection, methotrexate sodium, 50 mg 50 MG 2.325 20% - - - - -
J9261 - Injection, nelarabine, 50 mg 50 MG 116.647 20% - - - - -
J9262 - Injection, omacetaxine mepesuccinate, 0.01 mg 0.01 MG 3.962 19.3775235218786% - - - - -
* 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