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 7 * 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
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 4777.441 - - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.64 - - - - - -
J1170 - Injection, hydromorphone, up to 4 mg 4 MG 4.755 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 91.09 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.823 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 14.971 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 87.755 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 680.161 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 20.607 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.857 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.738 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 9.261 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.815 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.835 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 545.617 - - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 225.703 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 21.832 - - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 17.769 - - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 221.745 - - - - - -
J1304 - Injection, tofersen, 1 mg 1 MG 150.838 - - - - - -
J1305 - Injection, evinacumab-dgnb, 5mg 5 MG 179.14 - - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.119 - - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 283.224 - - - - - -
J1323 - Injection, elranatamab-bcmm, 1 mg 1 MG 181.673 - - - - - -
J1325 - Injection, epoprostenol, 0.5 mg 0.5 MG 15.648 - - - - - -
* 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