ASP Drug Pricing - (4th Quarter)
October 2022
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2022 (2nd 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 6 * Effective October 1, 2022 - December 31, 2022
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 4294.082 - - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.453 - - - - - -
J1170 - Injection, hydromorphone, up to 4 mg 4 MG 3.465 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 156.701 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 1.171 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 15.081 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 74.418 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 636.542 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 16.328 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.372 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.696 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 6.537 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.714 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.323 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 520.226 - - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 227.704 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 21.415 - - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 223.358 - - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.053 - - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 262.674 - - - - - -
J1325 - Injection, epoprostenol, 0.5 mg 0.5 MG 15.856 - - - - - -
J1335 - Injection, ertapenem sodium, 500 mg 500 MG 15.238 - - - - - -
J1364 - Injection, erythromycin lactobionate, per 500 mg 500 MG 82.897 - - - - - -
J1380 - Injection, estradiol valerate, up to 10 mg 10 MG 10.359 - - - - - -
J1410 - Injection, estrogen conjugated, per 25 mg 25 MG 355.491 - - - - - -
* Effective October 1, 2022 - December 31, 2022

Drugs not otherwise classified - October 2022

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2022 - December 31, 2022

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.162
Allopurinol Sodium 500 MG 2889.811
Aminocaproic acid 250 MG 0.329
Aztreonam 500 MG 14.801
Bortezomib (Dr. Reddy's) 0.1 MG 17.974
Bumetanide 0.25 MG 0.35
Bupivacaine 1 ML 0.123
Clindamycin Phosphate 150 MG 1.018
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.826 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.307
Doxycycline Hyclate 100 MG 17.103
Esmolol Hydrochloride 10 MG 0.299
Famotidine 10 MG 0.346
Flumazenil 0.1 MG 0.938
Folic Acid 5 MG 3.289
Glucarpidase 10 UNITS 362.572
Glycopyrrolate injection 0.2 MG 1.982
Immune Globulin (Panzyga) 500 MG 69.638
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 Units 8.461 Added October 2022
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 Units 15.871 Added October 2022
Labetalol Hcl 5 MG 0.186
Metoprolol Tartrate 1 MG 0.152
Metronidazole inj 500 MG 1.401
Nitroglycerin 5 MG 1.362
Olanzapine short acting intramuscular injection 0.5 MG 1.042
Paliperidone Palmitate (Invega Trinza) 1 MG 11.288
Rifampin 600 MG 95.198
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.373
Sulfamethoxazole-Trimethoprim 400-80 MG 0.669
Vasopressin 20 UNITS 172.139
Vasopressin (American Regent) 20 UNITS 136.351 Added October 2022

ASP (Average Sale Price) Drug Pricing History