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 5 * 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
J0713 - Injection, ceftazidime, per 500 mg 500 MG 1.694 - - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 95.449 - - - - - -
J0717 - Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 1 MG 4.816 - - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 23.174 - - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 19.267 - - - - - -
J0736 - Injection, clindamycin phosphate, 300 mg 300 MG 1.904 - - - - - -
J0737 - Injection, clindamycin phosphate (baxter), not therapeutically equivalent to j0736, 300 mg 300 MG 1.751 - - - - - -
J0740 - Injection, cidofovir, 375 mg 375 MG 554.192 - - - - - -
J0741 - Injection, cabotegravir and rilpivirine, 2mg/3mg 2MG/3MG 22.597 - - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.462 - - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 8.103 - - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 1.933 - - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 13.916 - - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 66.269 - - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 3.429 - - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 127.102 - - - - - -
J0801 - Injection, corticotropin (acthar gel), up to 40 units 40 UNITS 4095.318 - - - - - -
J0802 - Injection, corticotropin (ani), up to 40 units up to 40 Units 3348.991 - - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 27.114 - - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 1949.917 - - - - - -
J0841 - Injection, crotalidae immune f(ab')2 (equine), 120 mg 120 MG 912.076 - - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1807.872 - - - - - -
J0873 - Injection, daptomycin (xellia), not therapeutically equivalent to j0878 or j0872, 1 mg 1 MG 0.05 - - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 15.293 - - - - - -
J0877 - Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg 1 MG 0.065 - - - - - -
* 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