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 8 * 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
J1448 - Injection, trilaciclib, 1mg 1 MG 5.2 20% - - - - -
J1449 - Injection, eflapegrastim-xnst, 0.1 mg 0.1 MG 31.344 20% - - - - -
J1450 - Injection fluconazole, 200 mg 200 MG 2.306 20% - - - - -
J1453 - Injection, fosaprepitant, 1 mg 1 MG 0.120272393478703 20% - - - - -
J1454 - Injection, fosnetupitant 235 mg and palonosetron 0.25 mg 0.25 MG 528.379 20% - - - - -
J1456 - Injection, fosaprepitant (teva), not therapeutically equivalent to j1453, 1 mg 1 MG 0.174 20% - - - - -
J1458 - Injection, galsulfase, 1 mg 1 MG 463.043 20% - - - - -
J1459 - Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 47.589 20% - - - - -
J1460 - Injection, gamma globulin, intramuscular, 1 cc 1 CC 48.766 20% - - - - -
J1551 - Injection, immune globulin (cutaquig), 100 mg 100 MG 14.042 20% - - - - -
J1554 - Injection, immune globulin (asceniv), 500 mg 500 MG 491.405 20% - - - - -
J1555 - Injection, immune globulin (cuvitru), 100 mg 100 MG 15.725 20% - - - - -
J1556 - Injection, immune globulin (bivigam), 500 mg 500 MG 72.962 20% - - - - -
J1557 - Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 57.01 20% - - - - -
J1558 - Injection, immune globulin (xembify), 100 mg 100 MG 13.971 20% - - - - -
J1559 - Injection, immune globulin (hizentra), 100 mg 100 MG 12.728 20% - - - - -
J1560 - Injection, gamma globulin, intramuscular, over 10 cc 10 CC 487.656 20% - - - - -
J1561 - Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg 500 MG 49.262 20% - - - - -
J1566 - Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg 500 MG 76.567 20% - - - - -
J1568 - Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 44.786 20% - - - - -
J1569 - Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg 500 MG 44.46 20% - - - - -
J1570 - Injection, ganciclovir sodium, 500 mg 500 MG 29.992 20% - - - - -
J1571 - Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml 0.5 ML 62.164 20% - - - - -
J1575 - Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin 100 MG 16.888 20% - - - - -
J1576 - Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 65.704 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