ASP Drug Pricing - (1st Quarter)
January 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2023 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 4 * Effective January 1, 2024 through March 31, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 64.356 - - - - - -
J0598 - Injection, c-1 esterase inhibitor (human), cinryze, 10 units 10 UNITS 62.556 - - - - - -
J0612 - Injection, calcium gluconate, not otherwise specified, 10 mg 10 MG 0.05 - - - - - -
J0613 - Injection, calcium gluconate (wg critical care), not therapeutically equivalent to j0612, 10 mg 10 MG 0.089 - - - - - -
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 1069.499 - - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 5.427 - - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 124.326 - - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 4.47 - - - - - -
J0641 - Injection, levoleucovorin, not otherwise specified, 0.5 mg 0.5 MG 0.068 - - - - - -
J0642 - Injection, levoleucovorin (khapzory), 0.5 mg 0.5 MG 1.53 - - - - - -
J0665 - Injection, bupivicaine, not otherwise specified, 0.5 mg 0.5 MG 0.014 - - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.29 - - - - - -
J0688 - Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg 500 MG 1.042 - - - - - -
J0689 - Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg 500 MG 1.228 - - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.763 - - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.262 - - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 5.079 - - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 7.37 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.491 - - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 2.026 - - - - - -
J0699 - Injection, cefiderocol, 10 mg 10 mg 2.173 - - - - - -
J0701 - Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.637 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.816 - - - - - -
J0703 - Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.268 - - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.835 - - - - - -
* Effective January 1, 2024 through March 31, 2024

Drugs not otherwise classified - January 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2024 through March 31, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.29
Aztreonam 500 MG 14.778
Diltiazem Hydrochloride 5 MG 0.372
Doxycycline Hyclate 100 MG 15.942
Famotidine 10 MG 0.412
Flumazenil 0.1 MG 0.799
Folic Acid 5 MG 2.873
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Glycopyrrolate injection (Fresenius Kabi) 0.1 MG 2.698 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.144
Rifampin 600 MG 58.761
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.393
Sulfamethoxazole-Trimethoprim 400-80 MG 0.744

ASP (Average Sale Price) Drug Pricing History