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 22 * 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
J9060 - Injection, cisplatin, powder or solution, 10 mg 10 MG 3.172 20% - - - - -
J9061 - Injection, amivantamab-vmjw, 2 mg 2 MG 19.631 19.99% - - - - -
J9063 - Injection, mirvetuximab soravtansine-gynx, 1 mg 1 MG 65.802 20% - - - - -
J9065 - Injection, cladribine, per 1 mg 1 MG 18.296 20% - - - - -
J9070 - Cyclophosphamide, 100 mg 100 MG 17.087 20% - - - - -
J9071 - Injection, cyclophosphamide (auromedics), 5 mg 5 MG 3.869 20% - - - - -
J9100 - Injection, cytarabine, 100 mg 100 MG 0.917 20% - - - - -
J9118 - Injection, calaspargase pegol-mknl, 10 units 10 UNIT 72.869 20% - - - - -
J9119 - Injection, cemiplimab-rwlc, 1 mg 1 MG 26.923 20% - - - - -
J9120 - Injection, dactinomycin, 0.5 mg 0.5 MG 594.546 20% - - - - -
J9130 - Dacarbazine, 100 mg 100 MG 4.05 20% - - - - -
J9144 - Injection, daratumumab, 10 mg and hyaluronidase-fihj 10 MG 49.12 20% - - - - -
J9145 - Injection, daratumumab, 10 mg 10 MG 61.783 20% - - - - -
J9150 - Injection, daunorubicin, 10 mg 10 MG 45.622 20% - - - - -
J9153 - Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine 1 MG/2.27 MG 227.232 20% - - - - -
J9155 - Injection, degarelix, 1 mg 1 MG 4.194 20% - - - - -
J9171 - Injection, docetaxel, 1 mg 1 MG 0.937 20% - - - - -
J9173 - Injection, durvalumab, 10 mg 10 MG 79.763 20% - - - - -
J9176 - Injection, elotuzumab, 1 mg 1 MG 7.191 20% - - - - -
J9177 - Injection, enfortumab vedotin-ejfv, 0.25 mg 0.25 MG 33.818 19.658% - - - - -
J9178 - Injection, epirubicin hcl, 2 mg 2 MG 1.344 20% - - - - -
J9179 - Injection, eribulin mesylate, 0.1 mg 0.1 MG 128.777 20% - - - - -
J9181 - Injection, etoposide, 10 mg 10 MG 0.704 20% - - - - -
J9185 - Injection, fludarabine phosphate, 50 mg 50 MG 604.748 20% - - - - -
J9190 - Injection, fluorouracil, 500 mg 500 MG 1.83 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