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 21 * 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
J9017 - Injection, arsenic trioxide, 1 mg 1 MG 12.966 20% - - - - -
J9021 - Injection, asparaginase, recombinant, (rylaze), 0.1 mg 0.1 MG 49.53 20% - - - - -
J9022 - Injection, atezolizumab, 10 mg 10 MG 82.678 20% - - - - -
J9023 - Injection, avelumab, 10 mg 10 MG 90.569 20% - - - - -
J9025 - Injection, azacitidine, 1 mg 1 MG 0.402 20% - - - - -
J9027 - Injection, clofarabine, 1 mg 1 MG 29.424 20% - - - - -
J9030 - Bcg live intravesical instillation, 1 mg 1 MG 2.894 20% - - - - -
J9032 - Injection, belinostat, 10 mg 10 MG 47.622 20% - - - - -
J9033 - Injection, bendamustine hydrochloride, 1 mg 1 MG 12.282 20% - - - - -
J9034 - Injection, bendamustine hcl (bendeka), 1 mg 1 MG 16.508 20% - - - - -
J9035 - Injection, bevacizumab, 10 mg 10 MG 73.579 20% - - - - -
J9036 - Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mg 1 MG 16.716 20% - - - - -
J9039 - Injection, blinatumomab, 1 microgram 1 MCG 144.683 19.331% - - - - -
J9040 - Injection, bleomycin sulfate, 15 units 15 UNITS 24.533 20% - - - - -
J9041 - Injection, bortezomib, 0.1 mg 0.1 MG 3.031 20% - - - - -
J9042 - Injection, brentuximab vedotin, 1 mg 1 MG 221.964 19.494% - - - - -
J9043 - Injection, cabazitaxel, 1 mg 1 MG 206.032 20% - - - - -
J9045 - Injection, carboplatin, 50 mg 50 MG 2.408 20% - - - - -
J9046 - Injection, bortezomib (dr. reddy's), not therapeutically equivalent to j9041, 0.1 mg 0.1 MG 48.547 20% - - - - -
J9047 - Injection, carfilzomib, 1 mg 1 MG 47.04 19.685% - - - - -
J9049 - Injection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg 0.1 MG 3.892 20% - - - - -
J9050 - Injection, carmustine, 100 mg 100 MG 410.962 20% - - - - -
J9055 - Injection, cetuximab, 10 mg 10 MG 72.078 20% - - - - -
J9056 - Injection, bendamustine hydrochloride (vivimusta), 1 mg 1 MG 33.325 20% - - - - -
J9059 - Injection, bendamustine hydrochloride (baxter), 1 mg 1 MG 23.958 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