ASP Drug Pricing - (4th Quarter)
October 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2023 (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 2 * Effective October 1, 2023 - December 31, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0180 - Injection, agalsidase beta, 1 mg 1 MG 217.597 20% - - - - -
J0185 - Injection, aprepitant, 1 mg 1 MG 1.738 20% - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 2292.77 20% - - - - -
J0206 - Injection, allopurinol sodium, 1 mg 1 MG 5.634 20% - - - - -
J0218 - Injection, olipudase alfa-rpcp, 1 mg 1 MG 377.113 20% - - - - -
J0219 - Injection, avalglucosidase alfa-ngpt, 4 mg 4 MG 75.632 20% - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 197.073 20% - - - - -
J0222 - Injection, patisiran, 0.1 mg 0.1 MG 100.171 20% - - - - -
J0223 - Injection, givosiran, 0.5 mg 0.5 MG 112.096 20% - - - - -
J0224 - Injection, lumasiran, 0.5 mg 0.5 MG 319.496 20% - - - - -
J0225 - Injection, vutrisiran, 1 mg 1 MG 4950.374 20% - - - - -
J0248 - Injection, remdesivir, 1 mg 1 MG 6.058 20% - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.806 20% - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 5.417 20% - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 0.935 20% - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 10.593 20% - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 24.62 20% - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 27.923 20% - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.945 20% - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.578 19.7392983345491% - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.048 20% - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.545 20% - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 5.758 20% - - - - -
J0401 - Injection, aripiprazole (abilify maintena), 1 mg 1 MG 6.815 20% - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 1.787 20% - - - - -
* Effective October 1, 2023 - December 31, 2023

Drugs not otherwise classified - October 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2023 - December 31, 2023

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.287
Aztreonam 500 MG 14.712
Bumetanide 0.25 MG 0.391
Carmustine (Accord) 100 MG 594.083
Diltiazem Hydrochloride 5 MG 0.342
Doxycycline Hyclate 100 MG 15.616
Famotidine 10 MG 0.408
Flumazenil 0.1 MG 0.795
Folic Acid 5 MG 2.905
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.345 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 4.884 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.14171822859631
Rifampin 600 MG 84.394
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.692
Sulfamethoxazole-Trimethoprim 400-80 MG 0.636

ASP (Average Sale Price) Drug Pricing History