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 14 * 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
J2785 - Injection, regadenoson, 0.1 mg 0.1 MG 62.275 20% - - - - -
J2786 - Injection, reslizumab, 1 mg 1 MG 10.198 20% - - - - -
J2788 - Injection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.) 50 MCG (250 IU) 26.918 20% - - - - -
J2790 - Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) 300 MCG (1500 IU) 81.831 20% - - - - -
J2791 - Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu 100 IU 4.901 20% - - - - -
J2792 - Injection, rho d immune globulin, intravenous, human, solvent detergent, 100 iu 100 IU 33.71 20% - - - - -
J2794 - Injection, risperidone (risperdal consta), 0.5 mg 0.5 MG 12.023 20% - - - - -
J2795 - Injection, ropivacaine hydrochloride, 1 mg 1 MG 0.074 20% - - - - -
J2796 - Injection, romiplostim, 10 micrograms 10 MCG 95.468 19.718% - - - - -
J2798 - Injection, risperidone, (perseris), 0.5 mg 0.5 mg 11.669 20% - - - - -
J2800 - Injection, methocarbamol, up to 10 ml 10 ML 6.65 20% - - - - -
J2805 - Injection, sincalide, 5 micrograms 5 MCG 133.543 20% - - - - -
J2820 - Injection, sargramostim (gm-csf), 50 mcg 50 MCG 58.311 19.422% - - - - -
J2860 - Injection, siltuximab, 10 mg 10 MG 139.218 20% - - - - -
J2916 - Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg 12.5 MG 2.123 20% - - - - -
J2920 - Injection, methylprednisolone sodium succinate, up to 40 mg 40 MG 4.237 20% - - - - -
J2930 - Injection, methylprednisolone sodium succinate, up to 125 mg 125 MG 5.725 20% - - - - -
J2997 - Injection, alteplase recombinant, 1 mg 1 MG 89.146 20% - - - - -
J2998 - Injection, plasminogen, human-tvmh, 1 mg 1 MG 30.095 20% - - - - -
J3000 - Injection, streptomycin, up to 1 gm 1 GM 31.568 20% - - - - -
J3010 - Injection, fentanyl citrate, 0.1 mg 0.1 MG 0.837 20% - - - - -
J3032 - Injection, eptinezumab-jjmr, 1 mg 1 MG 17.443 20% - - - - -
J3060 - Injection, taliglucerase alfa, 10 units 10 UNITS 44.561 20% - - - - -
J3090 - Injection, tedizolid phosphate, 1 mg 1 MG 1.709 20% - - - - -
J3095 - Injection, telavancin, 10 mg 10 MG 6.826 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