ASP Drug Pricing - (3rd Quarter)
July 2022
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2022 (1st 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 4 * Effective Jul 1, 2022 through Sep 30, 2022
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.143 - - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.755 - - - - - -
J0691 - Injection, lefamulin, 1 mg 1 MG 0.724 - - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.776 - - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 4.633 - - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 6.395 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.51 - - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 2.038 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.554 - - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.725 - - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 2.092 - - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 91.786 - - - - - -
J0717 - Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 1 MG 5.581 - - - - - -
J0720 - Injection, chloramphenicol sodium succinate, up to 1 gm 1 GM 35.08553066 - - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 24.529 - - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 26.304 - - - - - -
J0740 - Injection, cidofovir, 375 mg 375 MG 583.011 - - - - - -
J0741 - Injection, cabotegravir and rilpivirine, 2mg/3mg 2MG/3MG 21.053 - - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.38 - - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 8.281 - - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 1.103 - - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 15.167 - - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 58.871 - - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 3.995 - - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 125.057 - - - - - -
* Effective Jul 1, 2022 through Sep 30, 2022

Drugs not otherwise classified - July 2022

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective Jul 1, 2022 through Sep 30, 2022

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 0.851
Allopurinol Sodium 500 MG 2741.738
Aminocaproic acid 250 MG 0.314
Aztreonam 500 MG 13.988
Bortezomib (Dr. Reddy's) 0.1 MG 23.125 Added July 2022
Bumetanide 0.25 MG 0.307
Bupivacaine 1 ML 0.113
Clindamycin Phosphate 150 MG 0.954
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.746 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.295
Doxycycline Hyclate 100 MG 16.117
Esmolol Hydrochloride 10 MG 0.297
Famotidine 10 MG 0.329
Flumazenil 0.1 MG 0.885
Folic Acid 5 MG 3.029
Glucarpidase 10 UNITS 362.572
Glycopyrrolate injection 0.2 MG 1.585
Immune Globulin (Panzyga) 500 MG 69.35
Labetalol Hcl 5 MG 0.13
Metoprolol Tartrate 1 MG 0.146
Metronidazole inj 500 MG 1.425
Nitroglycerin 5 MG 1.29
Olanzapine short acting intramuscular injection 0.5 MG 1.098
Paliperidone Palmitate (Invega Trinza) 1 MG 11.181
Rifampin 600 MG 68.27
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.36
Sulfamethoxazole-Trimethoprim 400-80 MG 0.677
Vasopressin 20 UNITS 189.538

ASP (Average Sale Price) Drug Pricing History