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 15 * 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
J3101 - Injection, tenecteplase, 1 mg 1 MG 152.696 20% - - - - -
J3105 - Injection, terbutaline sulfate, up to 1 mg 1 MG 2.29 20% - - - - -
J3111 - Injection, romosozumab-aqqg, 1 mg 1 MG 10.367 20% - - - - -
J3121 - Injection, testosterone enanthate, 1 mg 1 MG 0.047 20% - - - - -
J3145 - Injection, testosterone undecanoate, 1 mg 1 MG 1.904 18.825% - - - - -
J3230 - Injection, chlorpromazine hcl, up to 50 mg 50 MG 35.95 20% - - - - -
J3240 - Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial 0.9 MG 2001.485 20% - - - - -
J3241 - Injection, teprotumumab-trbw, 10 mg 10 MG 327.998 20% - - - - -
J3243 - Injection, tigecycline, 1 mg 1 MG 0.743 20% - - - - -
J3245 - Injection, tildrakizumab, 1 mg 1 MG 143.265 20% - - - - -
J3250 - Injection, trimethobenzamide hcl, up to 200 mg 200 MG 45.041 20% - - - - -
J3260 - Injection, tobramycin sulfate, up to 80 mg 80 MG 2.652 20% - - - - -
J3262 - Injection, tocilizumab, 1 mg 1 MG 5.91 20% - - - - -
J3285 - Injection, treprostinil, 1 mg 1 MG 55.196 20% - - - - -
J3299 - Injection, triamcinolone acetonide (xipere), 1 mg 1 MG 48.486 20% - - - - -
J3300 - Injection, triamcinolone acetonide, preservative free, 1 mg 1 MG 4.269 20% - - - - -
J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg 10 MG 1.005 20% - - - - -
J3304 - Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg 1 MG 17.114 20% - - - - -
J3315 - Injection, triptorelin pamoate, 3.75 mg 3.75 MG 382.392 20% - - - - -
J3357 - Ustekinumab, for subcutaneous injection, 1 mg 1 MG 147.647 20% - - - - -
J3358 - Ustekinumab, for intravenous injection, 1 mg 1 MG 12.594 20% - - - - -
J3360 - Injection, diazepam, up to 5 mg 5 MG 5.25 20% - - - - -
J3370 - Injection, vancomycin hcl, 500 mg 500 MG 2.409 20% - - - - -
J3371 - Injection, vancomycin hcl (mylan), not therapeutically equivalent to j3370, 500 mg 500 MG 6.298 20% - - - - -
J3372 - Injection, vancomycin hcl (xellia), not therapeutically equivalent to j3370, 500 mg 500 MG 6.578 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