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 7 * 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
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 1.062 20% - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 15.065 20% - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 61.567 20% - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 682.516 20% - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 17.143 20% - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.977 20% - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.777 20% - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 8.825 20% - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.699 20% - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.443 20% - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 530.72 20% - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 225.791 20% - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 21.402 20% - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 17.754 19.825% - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 221.875 20% - - - - -
J1305 - Injection, evinacumab-dgnb, 5mg 5 MG 175.777 20% - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.059 20% - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 280.126 20% - - - - -
J1325 - Injection, epoprostenol, 0.5 mg 0.5 MG 15.999 20% - - - - -
J1335 - Injection, ertapenem sodium, 500 mg 500 MG 13.322 20% - - - - -
J1364 - Injection, erythromycin lactobionate, per 500 mg 500 MG 87.328 20% - - - - -
J1380 - Injection, estradiol valerate, up to 10 mg 10 MG 10.782 20% - - - - -
J1410 - Injection, estrogen conjugated, per 25 mg 25 MG 371.893 20% - - - - -
J1430 - Injection, ethanolamine oleate, 100 mg 100 MG 481.062 20% - - - - -
J1437 - Injection, ferric derisomaltose, 10 mg 10 MG 20.613 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