ASP Drug Pricing - (2nd Quarter)
April 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2023 (4th 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 27 * Effective April 1, 2024 through June 30, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J9380 - Injection, teclistamab-cqyv, 0.5 mg 0.5 MG 30.762 - - - - - -
J9381 - Injection, teplizumab-mzwv, 5 mcg 5 MCG 36.38 - - - - - -
J9390 - Injection, vinorelbine tartrate, 10 mg 10 MG 8.499 - - - - - -
J9394 - Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg 25 MG 5.286 - - - - - -
J9395 - Injection, fulvestrant, 25 mg 25 MG 8.169 - - - - - -
J9400 - Injection, ziv-aflibercept, 1 mg 1 MG 6.682 - - - - - -
P9041 - Infusion, albumin (human), 5%, 50 ml 50 ML 10.615 - - - - 95% 10.615
P9045 - Infusion, albumin (human), 5%, 250 ml 250 ML 53.077 - - - - 95% 53.077
P9046 - Infusion, albumin (human), 25%, 20 ml 20 ML 21.231 - - - - 95% 21.231
P9047 - Infusion, albumin (human), 25%, 50 ml 50 ML 53.077 - - - - 95% 53.077
Q0138 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) 1 MG 0.394 - - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.394 - - - - - -
Q0162 - Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 1 MG 0.017 - - - - - -
Q0167 - Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 2.5 MG 0.842 - - - - - -
Q0249 - Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, 1 mg 1 MG 6.572 95% 6.572 - - - -
Q2041 - Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION CAR T CELLS 459381.446 - - - - - -
Q2042 - Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose up to 600 million CAR-positive viable T cells 518240.68 - - - - - -
Q2043 - Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion Per infusion (minimum 50 million cells) 55453.567 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 114.936 - - - - - -
Q2053 - Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR POSITIVE VIABLE T CEL 449440 - - - - - -
Q2054 - Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose Up to 110 million CAR-positive viable T cells, per therapeutic d 474060.62 - - - - - -
Q2055 - Idecabtagene vicleucel, up to 510 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 460 MILLION AUTOLOGOUS ANTI-BCMA CAR-POSITIVE VIABLE T CEL 484690.3 - - - - - -
Q2056 - Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose up to 100 million autologous b-cell maturation antigen (bcma) di 507495.551 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 54.28 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 146.892 - - - - - -
* Effective April 1, 2024 through June 30, 2024

Drugs not otherwise classified - April 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2024 through June 30, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.281
Aztreonam 500 MG 14.544
Diltiazem Hydrochloride 5 MG 0.354
Doxycycline Hyclate 100 MG 16.001
Famotidine 10 MG 0.391
Flumazenil 0.1 MG 1.21
Folic Acid 5 MG 2.833
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Glycopyrrolate injection (Fresenius Kabi) 0.1 MG 1.978 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.138
Rifampin 600 MG 89.91
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.447
Sulfamethoxazole-Trimethoprim 400-80 MG 0.708

ASP (Average Sale Price) Drug Pricing History