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 9 * 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
J1559 - Injection, immune globulin (hizentra), 100 mg 100 MG 12.907 - - - - - -
J1560 - Injection, gamma globulin, intramuscular, over 10 cc 10 CC 490.615 - - - - - -
J1561 - Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg 500 MG 48.883 - - - - - -
J1566 - Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg 500 MG 78.464 - - - - - -
J1568 - Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 46.98 - - - - - -
J1569 - Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg 500 MG 43.223 - - - - - -
J1570 - Injection, ganciclovir sodium, 500 mg 500 MG 44.095 - - - - - -
J1571 - Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml 0.5 ML 60.767 - - - - - -
J1575 - Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin 100 MG 16.941 - - - - - -
J1576 - Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 64.949 - - - - - -
J1580 - Injection, garamycin, gentamicin, up to 80 mg 80 MG 2.733 - - - - - -
J1596 - Injection, glycopyrrolate, 0.1 mg 0.1 MG 0.497 - - - - - -
J1602 - Injection, golimumab, 1 mg, for intravenous use 1 MG 11.801 - - - - - -
J1610 - Injection, glucagon hydrochloride, per 1 mg 1 MG 191.521 - - - - - -
J1611 - Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg 1 MG 128.884436702293 - - - - - -
J1626 - Injection, granisetron hydrochloride, 100 mcg 100 MCG 0.328 - - - - - -
J1627 - Injection, granisetron, extended-release, 0.1 mg 0.1 MG 5.424 - - - - - -
J1630 - Injection, haloperidol, up to 5 mg 5 MG 1.262 - - - - - -
J1631 - Injection, haloperidol decanoate, per 50 mg 50 MG 6.747 - - - - - -
J1640 - Injection, hemin, 1 mg 1 MG 31.354 - - - - - -
J1642 - Injection, heparin sodium, (heparin lock flush), per 10 units 10 UNITS 0.017 - - - - - -
J1643 - Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units 1000 UNITS 4.339 - - - - - -
J1644 - Injection, heparin sodium, per 1000 units 1000 UNITS 0.273 - - - - - -
J1645 - Injection, dalteparin sodium, per 2500 iu 2500 IU 16.596 - - - - - -
J1650 - Injection, enoxaparin sodium, 10 mg 10 MG 0.619 - - - - - -
* 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