ASP Drug Pricing - (2nd Quarter)
April 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2022 (4th 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 12 * Effective April 1, 2023 through June 30, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J2407 - Injection, oritavancin (orbactiv), 10 mg 10 MG 26.666 20% - - - - -
J2425 - Injection, palifermin, 50 micrograms 50 MCG 25.125 20% - - - - -
J2426 - Injection, paliperidone palmitate extended release (invega sustenna), 1 mg 1 MG 13.65 20% - - - - -
J2430 - Injection, pamidronate disodium, per 30 mg 30 MG 10.57 20% - - - - -
J2469 - Injection, palonosetron hcl, 25 mcg 25 MCG 1.297 20% - - - - -
J2501 - Injection, paricalcitol, 1 mcg 1 MCG 0.686485457195835 20% - - - - -
J2506 - Injection, pegfilgrastim, excludes biosimilar, 0.5 mg 0.5 MG 109.685 20% - - - - -
J2507 - Injection, pegloticase, 1 mg 1 MG 3201.861 20% - - - - -
J2510 - Injection, penicillin g procaine, aqueous, up to 600,000 units 600000 UNITS 39.335 20% - - - - -
J2540 - Injection, penicillin g potassium, up to 600,000 units 600000 UNITS 0.756 20% - - - - -
J2543 - Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 1.125 GM 1.336 20% - - - - -
J2545 - Pentamidine isethionate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 300 mg 300 MG 88.364 20% - - - - -
J2550 - Injection, promethazine hcl, up to 50 mg 50 MG 3.112 20% - - - - -
J2560 - Injection, phenobarbital sodium, up to 120 mg 120 MG 39.033 20% - - - - -
J2562 - Injection, plerixafor, 1 mg 1 MG 401.575 20% - - - - -
J2597 - Injection, desmopressin acetate, per 1 mcg 1 MCG 7.076 20% - - - - -
J2675 - Injection, progesterone, per 50 mg 50 MG 0.955 20% - - - - -
J2680 - Injection, fluphenazine decanoate, up to 25 mg 25 MG 9.599 20% - - - - -
J2690 - Injection, procainamide hcl, up to 1 gm 1 GM 164.374 20% - - - - -
J2700 - Injection, oxacillin sodium, up to 250 mg 250 MG 1.073 20% - - - - -
J2704 - Injection, propofol, 10 mg 10 MG 0.128 20% - - - - -
J2720 - Injection, protamine sulfate, per 10 mg 10 MG 0.86470045 20% - - - - -
J2724 - Injection, protein c concentrate, intravenous, human, 10 iu 10 UNITS 15.088 20% - - - - -
J2760 - Injection, phentolamine mesylate, up to 5 mg 5 MG 452.417 20% - - - - -
J2765 - Injection, metoclopramide hcl, up to 10 mg 10 MG 1.065 20% - - - - -
* Effective April 1, 2023 through June 30, 2023

Drugs not otherwise classified - April 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2023 through June 30, 2023

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.235
Allopurinol Sodium 500 MG 2979.421
Aminocaproic acid 250 MG 0.285
Aztreonam 500 MG 14.91
Bumetanide 0.25 MG 0.354
Bupivacaine 1 ML 0.143
Carmustine (Accord) 100 MG 723.117 Added April 2023
Clindamycin Phosphate 150 MG 0.997
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.779 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.327
Doxycycline Hyclate 100 MG 16.652
Esmolol Hydrochloride 10 MG 0.278
Famotidine 10 MG 0.405
Flumazenil 0.1 MG 0.969
Folic Acid 5 MG 2.525
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.28 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 5.048 Added April 2023 - providers must check the crosswalk file to determine the correct payment allowance
Immune Globulin (Panzyga) 500 MG 65.821
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 UNITS 7.19
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 UNITS 15.735
Labetalol Hcl 5 MG 0.272
Metoprolol Tartrate 1 MG 0.146
Metronidazole inj 500 MG 1.327
Nitroglycerin 5 MG 1.387
Olanzapine short acting intramuscular injection 0.5 MG 0.998
Paliperidone Palmitate (Invega Trinza) 1 MG 11.657
Rifampin 600 MG 102.954
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.746
Sulfamethoxazole-Trimethoprim 400-80 MG 0.746
Vasopressin 20 UNITS 101.775
Vasopressin (American Regent) 20 UNITS 86.938

ASP (Average Sale Price) Drug Pricing History