ASP Drug Pricing - (4th Quarter)
October 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2024 (2nd 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 10 * Effective October 1, 2024 - December 31, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J1630 - Injection, haloperidol, up to 5 mg 5 MG 1.03 - - - - - -
J1631 - Injection, haloperidol decanoate, per 50 mg 50 MG 6.781 - - - - - -
J1640 - Injection, hemin, 1 mg 1 MG 32.195 - - - - - -
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 3.734 - - - - - -
J1644 - Injection, heparin sodium, per 1000 units 1000 UNITS 0.219 - - - - - -
J1645 - Injection, dalteparin sodium, per 2500 iu 2500 IU 17.206 - - - - - -
J1650 - Injection, enoxaparin sodium, 10 mg 10 MG 0.57 - - - - - -
J1652 - Injection, fondaparinux sodium, 0.5 mg 0.5 MG 0.92 - - - - - -
J1670 - Injection, tetanus immune globulin, human, up to 250 units 250 UNITS 581.777 - - - - - -
J1720 - Injection, hydrocortisone sodium succinate, up to 100 mg 100 MG 19.397 - - - - - -
J1740 - Injection, ibandronate sodium, 1 mg 1 MG 27.136 - - - - - -
J1743 - Injection, idursulfase, 1 mg 1 MG 537.925 - - - - - -
J1745 - Injection, infliximab, excludes biosimilar, 10 mg 10 MG 32.223 - - - - - -
J1746 - Injection, ibalizumab-uiyk, 10 mg 10 MG 77.064 - - - - - -
J1747 - Injection, spesolimab-sbzo, 1 mg 1 MG 61.428 - - - - - -
J1750 - Injection, iron dextran, 50 mg 50 MG 17.669 - - - - - -
J1756 - Injection, iron sucrose, 1 mg 1 MG 0.233 - - - - - -
J1786 - Injection, imiglucerase, 10 units 10 UNITS 43.615 - - - - - -
J1805 - Injection, esmolol hydrochloride, 10 mg 10 MG 0.194 - - - - - -
J1806 - Injection, esmolol hydrochloride (wg critical care), not therapeutically equivalent to j1805, 10 mg 10 MG 0.358 - - - - - -
J1811 - Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 7.413 - - - - - -
J1813 - Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 15.534 - - - - - -
J1817 - Insulin for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 2.462 - - - - - -
J1823 - Injection, inebilizumab-cdon, 1 mg 1 MG 484.403 - - - - - -
* Effective October 1, 2024 - December 31, 2024

Drugs not otherwise classified - October 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2024 - December 31, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.319
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.783
Diltiazem Hydrochloride 5 MG 0.378
Doxycycline Hyclate 100 MG 12.923
Famotidine 10 MG 0.324
Flumazenil 0.1 MG 1.183
Folic Acid 5 MG 3.17
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Metoprolol Tartrate 1 MG 0.129
Rifampin 600 MG 91.656
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.393
Sulfamethoxazole-Trimethoprim 400-80 MG 0.629

ASP (Average Sale Price) Drug Pricing History