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 16 * 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
J3380 - Injection, vedolizumab, intravenous, 1 mg 1 MG 22.677 20% - - - - -
J3385 - Injection, velaglucerase alfa, 100 units 100 UNITS 367.181 20% - - - - -
J3396 - Injection, verteporfin, 0.1 mg 0.1 MG 11.416 20% - - - - -
J3410 - Injection, hydroxyzine hcl, up to 25 mg 25 MG 13.622 20% - - - - -
J3411 - Injection, thiamine hcl, 100 mg 100 MG 2.502 20% - - - - -
J3415 - Injection, pyridoxine hcl, 100 mg 100 MG 15.897 20% - - - - -
J3420 - Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 1000 MCG 1.31 20% - - - - -
J3430 - Injection, phytonadione (vitamin k), per 1 mg 1 MG 2.872 20% - - - - -
J3465 - Injection, voriconazole, 10 mg 10 MG 1.223 20% - - - - -
J3471 - Injection, hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 usp units) 1 UNIT 0.494 20% - - - - -
J3473 - Injection, hyaluronidase, recombinant, 1 usp unit 1 USP UNIT 0.359 20% - - - - -
J3475 - Injection, magnesium sulfate, per 500 mg 500 MG 0.934 20% - - - - -
J3480 - Injection, potassium chloride, per 2 meq 2 MEQ 0.101 20% - - - - -
J3485 - Injection, zidovudine, 10 mg 10 MG 1.512 20% - - - - -
J3486 - Injection, ziprasidone mesylate, 10 mg 10 MG 9.603 20% - - - - -
J3489 - Injection, zoledronic acid, 1 mg 1 MG 9.085 20% - - - - -
J7030 - Infusion, normal saline solution , 1000 cc 1000 ML 2.539 20% - - - - -
J7040 - Infusion, normal saline solution, sterile (500 ml = 1 unit) 500 ML 1.27 20% - - - - -
J7042 - 5% dextrose/normal saline (500 ml = 1 unit) 500 ML 1.178 20% - - - - -
J7050 - Infusion, normal saline solution, 250 cc 250 ML 0.635 20% - - - - -
J7060 - 5% dextrose/water (500 ml = 1 unit) 500 ML 1.812 20% - - - - -
J7070 - Infusion, d5w, 1000 cc 1000 CC 3.623 20% - - - - -
J7120 - Ringers lactate infusion, up to 1000 cc 1000 CC 2.389 20% - - - - -
J7170 - Injection, emicizumab-kxwh, 0.5 mg 0.5 MG 51.005 20% - - - - -
J7175 - Injection, factor x, (human), 1 i.u. 1 IU 9.091 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