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 20 * 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
J7611 - Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 1 mg 1 MG 0.133 20% - - - - -
J7612 - Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 0.5 mg 0.5 MG 0.254 20% - - - - -
J7613 - Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 1 mg 1 MG 0.03 20% - - - - -
J7614 - Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 0.5 mg 0.5 MG 0.035 20% - - - - -
J7620 - Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, fda-approved final product, non-compounded, administered through dme 2.5 MG/0.5 MG 0.131 20% - - - - -
J7626 - Budesonide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 0.5 mg 0.5 MG 0.878 20% - - - - -
J7631 - Cromolyn sodium, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 10 milligrams 10 MG 1.658 20% - - - - -
J7639 - Dornase alfa, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1 MG 52.234 20% - - - - -
J7644 - Ipratropium bromide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1 MG 0.258 20% - - - - -
J7674 - Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg 1 MG 0.863 20% - - - - -
J7677 - Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through dme, 1 microgram 1 MCG 0.196 20% - - - - -
J7682 - Tobramycin, inhalation solution, fda-approved final product, non-compounded, unit dose form, administered through dme, per 300 milligrams 300 MG 29.624 20% - - - - -
J7686 - Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg 1.74 MG 737.376 20% - - - - -
J8501 - Aprepitant, oral, 5 mg 5 MG 3.119 20% - - - - -
J8520 - Capecitabine, oral, 150 mg 150 MG 0.796 20% - - - - -
J8521 - Capecitabine, oral, 500 mg 500 MG 22.876 20% - - - - -
J8530 - Cyclophosphamide; oral, 25 mg 25 MG 0.953 20% - - - - -
J8540 - Dexamethasone, oral, 0.25 mg 0.25 MG 0.103 20% - - - - -
J8560 - Etoposide; oral, 50 mg 50 MG 77.388 20% - - - - -
J8610 - Methotrexate; oral, 2.5 mg 2.5 MG 0.232 20% - - - - -
J8655 - Netupitant 300 mg and palonosetron 0.5 mg, oral 0.5 MG 461.255 15.691% - - - - -
J8670 - Rolapitant, oral, 1 mg 1 MG 1.625 20% - - - - -
J8700 - Temozolomide, oral, 5 mg 5 MG 0.189 20% - - - - -
J8705 - Topotecan, oral, 0.25 mg 0.25 mg 112.3 20% - - - - -
J9000 - Injection, doxorubicin hydrochloride, 10 mg 10 MG 2.501 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