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 9 * 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
J1580 - Injection, garamycin, gentamicin, up to 80 mg 80 MG 2.922 20% - - - - -
J1602 - Injection, golimumab, 1 mg, for intravenous use 1 MG 12.931 20% - - - - -
J1610 - Injection, glucagon hydrochloride, per 1 mg 1 MG 187.503 20% - - - - -
J1611 - Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg 1 MG 110.7615482987 20% - - - - -
J1626 - Injection, granisetron hydrochloride, 100 mcg 100 MCG 0.385 20% - - - - -
J1627 - Injection, granisetron, extended-release, 0.1 mg 0.1 MG 5.78 20% - - - - -
J1630 - Injection, haloperidol, up to 5 mg 5 MG 1.241 20% - - - - -
J1631 - Injection, haloperidol decanoate, per 50 mg 50 MG 8.038 20% - - - - -
J1640 - Injection, hemin, 1 mg 1 MG 31.395 19.5359703638375% - - - - -
J1642 - Injection, heparin sodium, (heparin lock flush), per 10 units 10 UNITS 0.016 20% - - - - -
J1643 - Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units 1000 UNITS 5.183 20% - - - - -
J1644 - Injection, heparin sodium, per 1000 units 1000 UNITS 0.284 20% - - - - -
J1645 - Injection, dalteparin sodium, per 2500 iu 2500 IU 15.214 13.158% - - - - -
J1650 - Injection, enoxaparin sodium, 10 mg 10 MG 0.655 20% - - - - -
J1652 - Injection, fondaparinux sodium, 0.5 mg 0.5 MG 1.019 20% - - - - -
J1670 - Injection, tetanus immune globulin, human, up to 250 units 250 UNITS 584.386 19.2065977736839% - - - - -
J1720 - Injection, hydrocortisone sodium succinate, up to 100 mg 100 MG 17.672 20% - - - - -
J1740 - Injection, ibandronate sodium, 1 mg 1 MG 24.903 20% - - - - -
J1743 - Injection, idursulfase, 1 mg 1 MG 542.917 20% - - - - -
J1745 - Injection, infliximab, excludes biosimilar, 10 mg 10 MG 32.637 20% - - - - -
J1746 - Injection, ibalizumab-uiyk, 10 mg 10 MG 74.455 20% - - - - -
J1747 - Injection, spesolimab-sbzo, 1 mg 1 MG 60.223 20% - - - - -
J1750 - Injection, iron dextran, 50 mg 50 MG 17.407 20% - - - - -
J1756 - Injection, iron sucrose, 1 mg 1 MG 0.205316944729046 20% - - - - -
J1786 - Injection, imiglucerase, 10 units 10 UNITS 44.141 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