ASP Drug Pricing - (3rd Quarter)
July 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2024 (1st 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 20 * Effective Jul 1, 2024 through Sep 30, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J7351 - Injection, bimatoprost, intracameral implant, 1 microgram 1 MCG 208.381 - - - - - -
J7354 - Cantharidin for topical administration, 0.7%, single unit dose applicator (3.2 mg) Per 3.2 mg single-use applicator 719.584 - - - - - -
J7402 - Mometasone furoate sinus implant, (sinuva), 10 micrograms 10 MCG 11.345 - - - - - -
J7500 - Azathioprine, oral, 50 mg 50 MG 1.833 - - - - - -
J7502 - Cyclosporine, oral, 100 mg 100 MG 2.191 - - - - - -
J7503 - Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg 0.25 MG 1.767 - - - - - -
J7504 - Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg 250 MG 3982.594 - - - - - -
J7507 - Tacrolimus, immediate release, oral, 1 mg 1 MG 0.235 - - - - - -
J7508 - Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg 0.1 MG 0.563 - - - - - -
J7509 - Methylprednisolone oral, per 4 mg 4 MG 0.242 - - - - - -
J7510 - Prednisolone oral, per 5 mg 5 MG 0.239 - - - - - -
J7511 - Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg 25 MG 956.012 - - - - - -
J7512 - Prednisone, immediate release or delayed release, oral, 1 mg 1 MG 0.008 - - - - - -
J7515 - Cyclosporine, oral, 25 mg 25 MG 0.795 - - - - - -
J7517 - Mycophenolate mofetil, oral, 250 mg 250 MG 0.163 - - - - - -
J7518 - Mycophenolic acid, oral, 180 mg 180 MG 0.374 - - - - - -
J7519 - Injection, mycophenolate mofetil, 10 mg 10 MG 0.544 - - - - - -
J7520 - Sirolimus, oral, 1 mg 1 MG 1.335 - - - - - -
J7525 - Tacrolimus, parenteral, 5 mg 5 MG 253.607 - - - - - -
J7527 - Everolimus, oral, 0.25 mg 0.25 MG 2.202 - - - - - -
J7605 - Arformoterol, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 15 micrograms 15 mcg 1.463 - - - - - -
J7606 - Formoterol fumarate, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 20 micrograms 20 MCG 3.145 - - - - - -
J7608 - Acetylcysteine, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per gram 1 GM 9.109 - - - - - -
J7611 - Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 1 mg 1 MG 0.168 - - - - - -
J7612 - Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 0.5 mg 0.5 MG 0.271 - - - - - -
* Effective Jul 1, 2024 through Sep 30, 2024

Drugs not otherwise classified - July 2024

 

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

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.303
Aztreonam 500 MG 2.128
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.308 Added July 2024
Diltiazem Hydrochloride 5 MG 0.374
Doxycycline Hyclate 100 MG 13.505
Famotidine 10 MG 0.3
Flumazenil 0.1 MG 1.123
Folic Acid 5 MG 2.808
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 0.136
Rifampin 600 MG 49.595
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.432
Sulfamethoxazole-Trimethoprim 400-80 MG 0.572

ASP (Average Sale Price) Drug Pricing History