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 27 * 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
J9353 - Injection, margetuximab-cmkb, 5 mg 5 MG 48.14 - - - - - -
J9354 - Injection, ado-trastuzumab emtansine, 1 mg 1 MG 40.042 - - - - - -
J9355 - Injection, trastuzumab, excludes biosimilar, 10 mg 10 MG 78.082 - - - - - -
J9356 - Injection, trastuzumab, 10 mg and hyaluronidase-oysk 10 MG 64.612 - - - - - -
J9357 - Injection, valrubicin, intravesical, 200 mg 200 MG 1453.797 - - - - - -
J9358 - Injection, fam-trastuzumab deruxtecan-nxki, 1 mg 1 MG 27.752 - - - - - -
J9359 - Injection, loncastuximab tesirine-lpyl, 0.075 mg 0.075 MG 206.414 - - - - - -
J9360 - Injection, vinblastine sulfate, 1 mg 1 MG 3.88 - - - - - -
J9370 - Vincristine sulfate, 1 mg 1 MG 8.491 - - - - - -
J9380 - Injection, teclistamab-cqyv, 0.5 mg 0.5 MG 31.75 - - - - - -
J9381 - Injection, teplizumab-mzwv, 5 mcg 5 MCG 36.945 - - - - - -
J9390 - Injection, vinorelbine tartrate, 10 mg 10 MG 8.198 - - - - - -
J9394 - Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg 25 MG 12.257 - - - - - -
J9395 - Injection, fulvestrant, 25 mg 25 MG 8.726 - - - - - -
J9400 - Injection, ziv-aflibercept, 1 mg 1 MG 7.091 - - - - - -
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 0.331 - - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.331 - - - - - -
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 0.014 - - - - - -
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 2.688 - - - - - -
Q0224 - Injection, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, and who either have moderate-to-severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments, and are unlikely to mount an adequate immune response to covid-19 vaccination, 4500 mg 4500 MG 6583.5 95% 6583.5 - - - -
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 7.569 95% 7.569 - - - -
* 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