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 30 * 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
Q4262 - Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1006.323 20% - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 530 20% - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.17 20% - - - - -
Q5103 - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 10 MG 13.931 20% - - - - -
Q5104 - Injection, infliximab-abda, biosimilar, (renflexis), 10 mg 10 MG 32.562 20% - - - - -
Q5105 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units 100 UNITS 0.725 20% - - - - -
Q5106 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units 1000 UNITS 7.252 20% - - - - -
Q5107 - Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg 10 MG 27.853 20% - - - - -
Q5108 - Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg 0.5 MG 96.464 20% - - - - -
Q5110 - Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram 1 MCG 0.297 20% - - - - -
Q5111 - Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg 0.5 MG 150.78 20% - - - - -
Q5112 - Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg 10 MG 41.651 20% - - - - -
Q5113 - Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg 10 MG 20.183 20% - - - - -
Q5114 - Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg 10 MG 40.04 20% - - - - -
Q5115 - Injection, rituximab-abbs, biosimilar, (truxima), 10 mg 10 MG 37.626 20% - - - - -
Q5116 - Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg 10 MG 19.622 20% - - - - -
Q5117 - Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg 10 MG 24.341 20% - - - - -
Q5118 - Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg 10 MG 23.737 20% - - - - -
Q5119 - Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg 10 MG 22.304 20% - - - - -
Q5121 - Injection, infliximab-axxq, biosimilar, (avsola), 10 mg 10 MG 26.468 20% - - - - -
Q5122 - Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg 0.5 MG 88.98 20% - - - - -
Q5123 - Injection, rituximab-arrx, biosimilar, (riabni), 10 mg 10 MG 43.475 20% - - - - -
Q5124 - Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg 0.1 MG 199.552 20% - - - - -
Q5125 - Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram 1 MCG 0.525 20% - - - - -
Q5126 - Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg 10 MG 63.916 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