ASP Drug Pricing - (3rd Quarter)
July 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2023 (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 12 * Effective Jul 1, 2023 through Sep 30, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J2281 - Injection, moxifloxacin (fresenius kabi), not therapeutically equivalent to j2280, 100 mg 100 MG 4.495 20% - - - - -
J2300 - Injection, nalbuphine hydrochloride, per 10 mg 10 MG 2.716 20% - - - - -
J2305 - Injection, nitroglycerin, 5 mg 5 MG 1.296 20% - - - - -
J2310 - Injection, naloxone hydrochloride, per 1 mg 1 MG 9.45 20% - - - - -
J2311 - Injection, naloxone hydrochloride (zimhi), 1 mg 1 MG 8.508 20% - - - - -
J2315 - Injection, naltrexone, depot form, 1 mg 1 MG 3.94 19.948% - - - - -
J2323 - Injection, natalizumab, 1 mg 1 MG 24.863 20% - - - - -
J2327 - Injection, risankizumab-rzaa, intravenous, 1 mg 1 MG 15.519 20% - - - - -
J2350 - Injection, ocrelizumab, 1 mg 1 MG 61.417 20% - - - - -
J2353 - Injection, octreotide, depot form for intramuscular injection, 1 mg 1 MG 208.117 20% - - - - -
J2354 - Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg 25 MCG 1.314 20% - - - - -
J2356 - Injection, tezepelumab-ekko, 1 mg 1 MG 18.729 19.899% - - - - -
J2357 - Injection, omalizumab, 5 mg 5 MG 39.383 20% - - - - -
J2358 - Injection, olanzapine, long-acting, 1 mg 1 MG 2.917 20% - - - - -
J2360 - Injection, orphenadrine citrate, up to 60 mg 60 MG 16.536 20% - - - - -
J2372 - Injection, phenylephrine hydrochloride (biorphen), 20 micrograms 20 MCG 0.188 20% - - - - -
J2401 - Injection, chloroprocaine hydrochloride, per 1 mg 1 MG 0.039 20% - - - - -
J2405 - Injection, ondansetron hydrochloride, per 1 mg 1 MG 0.111 20% - - - - -
J2406 - Injection, oritavancin (kimyrsa), 10 mg 10 MG 41.734 20% - - - - -
J2407 - Injection, oritavancin (orbactiv), 10 mg 10 MG 26.894 20% - - - - -
J2426 - Injection, paliperidone palmitate extended release (invega sustenna), 1 mg 1 MG 14.217 20% - - - - -
J2427 - Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg 1MG 12.108 20% - - - - -
J2430 - Injection, pamidronate disodium, per 30 mg 30 MG 10.316 20% - - - - -
J2469 - Injection, palonosetron hcl, 25 mcg 25 MCG 1.001 20% - - - - -
J2501 - Injection, paricalcitol, 1 mcg 1 MCG 0.498 20% - - - - -
* Effective Jul 1, 2023 through Sep 30, 2023

Drugs not otherwise classified - July 2023

 

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

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.305
Aztreonam 500 MG 14.775
Bumetanide 0.25 MG 0.383
Carmustine (Accord) 100 MG 654.42
Diltiazem Hydrochloride 5 MG 0.342
Doxycycline Hyclate 100 MG 16.063
Famotidine 10 MG 0.417
Flumazenil 0.1 MG 0.812
Folic Acid 5 MG 2.586
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.348 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 4.852 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.151
Olanzapine short acting intramuscular injection 0.5 MG 0.9
Rifampin 600 MG 111.851
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.763
Sulfamethoxazole-Trimethoprim 400-80 MG 0.892

ASP (Average Sale Price) Drug Pricing History