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 7 * 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
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 17.516 20% - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.988 20% - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.688 20% - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 9.822 20% - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.63 20% - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.424 20% - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 532.245 20% - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 225.263 20% - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 21.385 20% - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 17.743 20% - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 221.669 20% - - - - -
J1305 - Injection, evinacumab-dgnb, 5mg 5 MG 179.14 20% - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.021 20% - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 280.922 20% - - - - -
J1325 - Injection, epoprostenol, 0.5 mg 0.5 MG 16.023 20% - - - - -
J1335 - Injection, ertapenem sodium, 500 mg 500 MG 13.1916413774561 20% - - - - -
J1364 - Injection, erythromycin lactobionate, per 500 mg 500 MG 83.636 20% - - - - -
J1380 - Injection, estradiol valerate, up to 10 mg 10 MG 10.622 20% - - - - -
J1410 - Injection, estrogen conjugated, per 25 mg 25 MG 372.476 20% - - - - -
J1430 - Injection, ethanolamine oleate, 100 mg 100 MG 469.257 20% - - - - -
J1437 - Injection, ferric derisomaltose, 10 mg 10 MG 20.059 20% - - - - -
J1439 - Injection, ferric carboxymaltose, 1 mg 1 MG 1.123 20% - - - - -
J1440 - Fecal microbiota, live - jslm, 1 ml 1 ML 62.423 20% - - - - -
J1442 - Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram 1 MCG 0.986 20% - - - - -
J1447 - Injection, tbo-filgrastim, 1 microgram 1 MCG 0.416 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