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 3 * 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
J0457 - Injection, aztreonam, 100 mg 100 MG 2.519 20% - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.088 20% - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 182.263 20% - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 46.921 20% - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4393.541 20% - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.786 20% - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 51.97 20% - - - - -
J0491 - Injection, anifrolumab-fnia, 1 mg 1 MG 16.595 20% - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 21.7996488171644 20% - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 22.277 20% - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 170.559 20% - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 15.742 17.7413800171293% - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 20.157 17.4836046109764% - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.844 20% - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 0.186 20% - - - - -
J0584 - Injection, burosumab-twza 1 mg 1 MG 433.522 19.744006340141% - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 6.325 20% - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.219 20% - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 13.042 20% - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.189 20% - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 4.18 20% - - - - -
J0594 - injection, busulfan, 1 mg 1 MG 1.044 20% - - - - -
J0595 - Injection, butorphanol tartrate, 1 mg 1 MG 2.543 20% - - - - -
J0596 - Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units 10 UNITS 33.7 20% - - - - -
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 64.406 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