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 18 * 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
J7329 - Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg 1 MG 9.669 20% - - - - -
J7331 - Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg 1 MG 13.25 20% - - - - -
J7332 - Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg 1 MG 9.903 20% - - - - -
J7336 - Capsaicin 8% patch, per square centimeter 1 SQ CM 3.276 20% - - - - -
J7340 - Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml 100 ML 219.761 20% - - - - -
J7342 - Instillation, ciprofloxacin otic suspension, 6 mg 6 MG 30.008 20% - - - - -
J7345 - Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg 10 MG 1.65 20% - - - - -
J7351 - Injection, bimatoprost, intracameral implant, 1 microgram 1 MCG 206.276 20% - - - - -
J7402 - Mometasone furoate sinus implant, (sinuva), 10 micrograms 10 MCG 11.345 20% - - - - -
J7500 - Azathioprine, oral, 50 mg 50 MG 14.624 20% - - - - -
J7502 - Cyclosporine, oral, 100 mg 100 MG 2.268 20% - - - - -
J7503 - Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg 0.25 MG 1.619 20% - - - - -
J7504 - Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg 250 MG 3001.29 17.83% - - - - -
J7507 - Tacrolimus, immediate release, oral, 1 mg 1 MG 0.35 20% - - - - -
J7508 - Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg 0.1 MG 0.523 20% - - - - -
J7509 - Methylprednisolone oral, per 4 mg 4 MG 0.271 20% - - - - -
J7510 - Prednisolone oral, per 5 mg 5 MG 0.264 20% - - - - -
J7511 - Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg 25 MG 886.375 20% - - - - -
J7512 - Prednisone, immediate release or delayed release, oral, 1 mg 1 MG 0.011 20% - - - - -
J7515 - Cyclosporine, oral, 25 mg 25 MG 0.745 20% - - - - -
J7517 - Mycophenolate mofetil, oral, 250 mg 250 MG 0.201 20% - - - - -
J7518 - Mycophenolic acid, oral, 180 mg 180 MG 0.643 20% - - - - -
J7520 - Sirolimus, oral, 1 mg 1 MG 2.937 20% - - - - -
J7525 - Tacrolimus, parenteral, 5 mg 5 MG 233.918 20% - - - - -
J7527 - Everolimus, oral, 0.25 mg 0.25 MG 3.116 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