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 14 * 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
J2760 - Injection, phentolamine mesylate, up to 5 mg 5 MG 446.797 - - - - - -
J2765 - Injection, metoclopramide hcl, up to 10 mg 10 MG 1.094 - - - - - -
J2777 - Injection, faricimab-svoa, 0.1 mg 0.1 MG 36.092 - - - - - -
J2778 - Injection, ranibizumab, 0.1 mg 0.1 mg 187.553 - - - - - -
J2779 - Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg 0.1 MG 80.782 - - - - - -
J2781 - Injection, pegcetacoplan, intravitreal, 1 mg 1 MG 151.462 - - - - - -
J2783 - Injection, rasburicase, 0.5 mg 0.5 MG 367.268 - - - - - -
J2785 - Injection, regadenoson, 0.1 mg 0.1 MG 14.28 - - - - - -
J2786 - Injection, reslizumab, 1 mg 1 MG 10.168 - - - - - -
J2788 - Injection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.) 50 MCG (250 IU) 23.799 - - - - - -
J2790 - Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) 300 MCG (1500 IU) 81.161 - - - - - -
J2791 - Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu 100 IU 4.827 - - - - - -
J2792 - Injection, rho d immune globulin, intravenous, human, solvent detergent, 100 iu 100 IU 32.964 - - - - - -
J2794 - Injection, risperidone (risperdal consta), 0.5 mg 0.5 MG 12.151 - - - - - -
J2795 - Injection, ropivacaine hydrochloride, 1 mg 1 MG 0.077 - - - - - -
J2796 - Injection, romiplostim, 10 micrograms 10 MCG 96.027 - - - - - -
J2798 - Injection, risperidone, (perseris), 0.5 mg 0.5 mg 11.624 - - - - - -
J2799 - Injection, risperidone (uzedy), 1 mg 1 MG 24.7 - - - - - -
J2800 - Injection, methocarbamol, up to 10 ml 10 ML 5.656 - - - - - -
J2805 - Injection, sincalide, 5 micrograms 5 MCG 133.099 - - - - - -
J2820 - Injection, sargramostim (gm-csf), 50 mcg 50 MCG 59.317 - - - - - -
J2860 - Injection, siltuximab, 10 mg 10 MG 148.943 - - - - - -
J2916 - Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg 12.5 MG 2.374 - - - - - -
J2920 - Injection, methylprednisolone sodium succinate, up to 40 mg 40 MG 4.188 - - - - - -
J2930 - Injection, methylprednisolone sodium succinate, up to 125 mg 125 MG 5.882 - - - - - -
* 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