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 9 * 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
J1557 - Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 54.566 - - - - - -
J1558 - Injection, immune globulin (xembify), 100 mg 100 MG 14.4 - - - - - -
J1559 - Injection, immune globulin (hizentra), 100 mg 100 MG 13.188 - - - - - -
J1560 - Injection, gamma globulin, intramuscular, over 10 cc 10 CC 500.711 - - - - - -
J1561 - Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg 500 MG 49.58 - - - - - -
J1566 - Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg 500 MG 79.899 - - - - - -
J1568 - Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 47.74 - - - - - -
J1569 - Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg 500 MG 45.072 - - - - - -
J1570 - Injection, ganciclovir sodium, 500 mg 500 MG 32.014 - - - - - -
J1571 - Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml 0.5 ML 62.779 - - - - - -
J1575 - Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin 100 MG 17.239 - - - - - -
J1576 - Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 69.765 - - - - - -
J1580 - Injection, garamycin, gentamicin, up to 80 mg 80 MG 2.066 - - - - - -
J1596 - Injection, glycopyrrolate, 0.1 mg 0.1 MG 0.455 - - - - - -
J1602 - Injection, golimumab, 1 mg, for intravenous use 1 MG 11.37 - - - - - -
J1610 - Injection, glucagon hydrochloride, per 1 mg 1 MG 189.462 - - - - - -
J1611 - Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg 1 MG 129.665 - - - - - -
J1626 - Injection, granisetron hydrochloride, 100 mcg 100 MCG 0.298 - - - - - -
J1627 - Injection, granisetron, extended-release, 0.1 mg 0.1 MG 5.629 - - - - - -
J1630 - Injection, haloperidol, up to 5 mg 5 MG 1.157 - - - - - -
J1631 - Injection, haloperidol decanoate, per 50 mg 50 MG 6.528 - - - - - -
J1640 - Injection, hemin, 1 mg 1 MG 32.118 - - - - - -
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 3.419 - - - - - -
J1644 - Injection, heparin sodium, per 1000 units 1000 UNITS 0.234 - - - - - -
* 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