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 6 * 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
J0888 - Injection, epoetin beta, 1 microgram, (for non esrd use) 1 MCG 1.71 20% - - - - -
J0891 - Injection, argatroban (accord), not therapeutically equivalent to j0883, 1 mg (for non-esrd use) 1 MG 0.371 20% - - - - -
J0892 - Injection, argatroban (accord), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis) 1 MG 0.371 20% - - - - -
J0893 - Injection, decitabine (sun pharma), not therapeutically equivalent to j0894, 1 mg 1 MG 2.12 20% - - - - -
J0894 - Injection, decitabine, 1 mg 1 MG 1.147 20% - - - - -
J0895 - Injection, deferoxamine mesylate, 500 mg 500 MG 8.591 20% - - - - -
J0896 - Injection, luspatercept-aamt, 0.25 mg 0.25 MG 39.205 20% - - - - -
J0897 - Injection, denosumab, 1 mg 1 MG 24.217 20% - - - - -
J1000 - Injection, depo-estradiol cypionate, up to 5 mg 5 MG 32.669 20% - - - - -
J1020 - Injection, methylprednisolone acetate, 20 mg 20 MG 7.099 20% - - - - -
J1030 - Injection, methylprednisolone acetate, 40 mg 40 MG 7.202 20% - - - - -
J1040 - Injection, methylprednisolone acetate, 80 mg 80 MG 10.757 20% - - - - -
J1071 - Injection, testosterone cypionate, 1 mg 1 MG 0.029 20% - - - - -
J1100 - Injection, dexamethasone sodium phosphate, 1 mg 1 MG 0.126 20% - - - - -
J1110 - Injection, dihydroergotamine mesylate, per 1 mg 1 MG 46.517 20% - - - - -
J1120 - Injection, acetazolamide sodium, up to 500 mg 500 MG 26.316 20% - - - - -
J1160 - Injection, digoxin, up to 0.5 mg 0.5 MG 11.357 20% - - - - -
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 4593.574 20% - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.461 20% - - - - -
J1170 - Injection, hydromorphone, up to 4 mg 4 MG 4.023 20% - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 123.87906501449 20% - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.846 20% - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 15.178 20% - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 76.733 20% - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 681.744 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