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 19 * 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
J7336 - Capsaicin 8% patch, per square centimeter 1 SQ CM 3.274 20% - - - - -
J7340 - Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml 100 ML 226.831 20% - - - - -
J7342 - Instillation, ciprofloxacin otic suspension, 6 mg 6 MG 30.019 20% - - - - -
J7345 - Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg 10 MG 1.649 20% - - - - -
J7351 - Injection, bimatoprost, intracameral implant, 1 microgram 1 MCG 206.406 20% - - - - -
J7402 - Mometasone furoate sinus implant, (sinuva), 10 micrograms 10 MCG 11.345 20% - - - - -
J7500 - Azathioprine, oral, 50 mg 50 MG 13.701 20% - - - - -
J7502 - Cyclosporine, oral, 100 mg 100 MG 1.759 20% - - - - -
J7503 - Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg 0.25 MG 1.673 20% - - - - -
J7504 - Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg 250 MG 2989.437 18.075% - - - - -
J7507 - Tacrolimus, immediate release, oral, 1 mg 1 MG 0.287 20% - - - - -
J7508 - Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg 0.1 MG 0.549 20% - - - - -
J7509 - Methylprednisolone oral, per 4 mg 4 MG 0.261 20% - - - - -
J7510 - Prednisolone oral, per 5 mg 5 MG 0.248 20% - - - - -
J7511 - Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg 25 MG 920.534 20% - - - - -
J7512 - Prednisone, immediate release or delayed release, oral, 1 mg 1 MG 0.006 20% - - - - -
J7515 - Cyclosporine, oral, 25 mg 25 MG 0.754 20% - - - - -
J7517 - Mycophenolate mofetil, oral, 250 mg 250 MG 0.212 20% - - - - -
J7518 - Mycophenolic acid, oral, 180 mg 180 MG 0.672 20% - - - - -
J7520 - Sirolimus, oral, 1 mg 1 MG 3.107 20% - - - - -
J7525 - Tacrolimus, parenteral, 5 mg 5 MG 246.085 20% - - - - -
J7527 - Everolimus, oral, 0.25 mg 0.25 MG 3.201 20% - - - - -
J7605 - Arformoterol, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 15 micrograms 15 mcg 3.286 20% - - - - -
J7606 - Formoterol fumarate, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 20 micrograms 20 MCG 5.189 20% - - - - -
J7608 - Acetylcysteine, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per gram 1 GM 6.844 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