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 5 * 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
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 92.479 20% - - - - -
J0717 - Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 1 MG 5.073 20% - - - - -
J0720 - Injection, chloramphenicol sodium succinate, up to 1 gm 1 GM 50.261 20% - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 23.077 20% - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 21.036 20% - - - - -
J0736 - Injection, clindamycin phosphate, 300 mg 300 MG 1.606 20% - - - - -
J0740 - Injection, cidofovir, 375 mg 375 MG 577.031 20% - - - - -
J0741 - Injection, cabotegravir and rilpivirine, 2mg/3mg 2MG/3MG 21.842 20% - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.488 20% - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 7.145 20% - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 1.955 20% - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 12.282 20% - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 65.148 19.101% - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 3.014 20% - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 126.606 20% - - - - -
J0800 - Injection, corticotropin, up to 40 units 40 UNITS 3819.78 20% - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 27.881 20% - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 2056.352 20% - - - - -
J0841 - Injection, crotalidae immune f(ab')2 (equine), 120 mg 120 MG 1019.456 20% - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1814.195 19.173% - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 14.703 20% - - - - -
J0877 - Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg 1 MG 0.071 20% - - - - -
J0878 - Injection, daptomycin, 1 mg 1 MG 0.078 20% - - - - -
J0881 - Injection, darbepoetin alfa, 1 microgram (non-esrd use) 1 MCG 2.936 20% - - - - -
J0882 - Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) 1 MCG 2.936 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