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 25 * 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
J9309 - Injection, polatuzumab vedotin-piiq, 1 mg 1 MG 121.234 20% - - - - -
J9311 - Injection, rituximab 10 mg and hyaluronidase 10 mg 37.133 20% - - - - -
J9312 - Injection, rituximab, 10 mg 10 MG 80.192 20% - - - - -
J9313 - Injection, moxetumomab pasudotox-tdfk, 0.01 mg 0.01 MG 23.394 20% - - - - -
J9316 - Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg 10 MG 67.906 20% - - - - -
J9317 - Injection, sacituzumab govitecan-hziy, 2.5 mg 2.5 MG 33.26 20% - - - - -
J9319 - Injection, romidepsin, lyophilized, 0.1 mg 0.1 MG 30.659 20% - - - - -
J9325 - Injection, talimogene laherparepvec, per 1 million plaque forming units 1 million PFU 66.295 19.7724288987441% - - - - -
J9328 - Injection, temozolomide, 1 mg 1 MG 10.4 20% - - - - -
J9330 - Injection, temsirolimus, 1 mg 1 MG 29.679 20% - - - - -
J9331 - Injection, sirolimus protein-bound particles, 1 mg 1 MG 107.658 20% - - - - -
J9332 - Injection, efgartigimod alfa-fcab, 2mg 2 MG 32.108 20% - - - - -
J9340 - Injection, thiotepa, 15 mg 15 MG 260.251 20% - - - - -
J9347 - Injection, tremelimumab-actl, 1 mg 1 MG 136.306 20% - - - - -
J9348 - Injection, naxitamab-gqgk, 1 mg 1 MG 579.537 20% - - - - -
J9349 - Injection, tafasitamab-cxix, 2 mg 2 MG 13.288 20% - - - - -
J9350 - Injection, mosunetuzumab-axgb, 1 mg 1 MG 629.703 20% - - - - -
J9351 - Injection, topotecan, 0.1 mg 0.1 MG 1.085 20% - - - - -
J9352 - Injection, trabectedin, 0.1 mg 0.1 MG 338.41 20% - - - - -
J9353 - Injection, margetuximab-cmkb, 5 mg 5 MG 45.93 20% - - - - -
J9354 - Injection, ado-trastuzumab emtansine, 1 mg 1 MG 38.339 20% - - - - -
J9355 - Injection, trastuzumab, excludes biosimilar, 10 mg 10 MG 80.785 20% - - - - -
J9356 - Injection, trastuzumab, 10 mg and hyaluronidase-oysk 10 MG 66 20% - - - - -
J9357 - Injection, valrubicin, intravesical, 200 mg 200 MG 1426.652 20% - - - - -
J9358 - Injection, fam-trastuzumab deruxtecan-nxki, 1 mg 1 MG 26.384 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