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 11 * 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
J1836 - Injection, metronidazole, 10 mg 10 MG 0.026 - - - - - -
J1885 - Injection, ketorolac tromethamine, per 15 mg 15 MG 0.682 - - - - - -
J1920 - Injection, labetalol hydrochloride, 5 mg 5 MG 0.267 - - - - - -
J1921 - Injection, labetalol hydrochloride (hikma), not therapeutically equivalent to j1920, 5 mg 5 MG 1.631 - - - - - -
J1930 - Injection, lanreotide, 1 mg 1 MG 49.971 - - - - - -
J1931 - Injection, laronidase, 0.1 mg 0.1 MG 38.698 - - - - - -
J1932 - Injection, lanreotide, (cipla), 1 mg 1 MG 36.803 - - - - - -
J1939 - Injection, bumetanide, 0.5 mg 0.5 MG 0.62 - - - - - -
J1940 - Injection, furosemide, up to 20 mg 20 MG 0.396 - - - - - -
J1943 - Injection, aripiprazole lauroxil, (aristada initio), 1 mg 1 MG 3.191 - - - - - -
J1944 - Injection, aripiprazole lauroxil, (aristada), 1 mg 1 MG 3.227 - - - - - -
J1950 - Injection, leuprolide acetate (for depot suspension), per 3.75 mg 3.75 MG 1617.647 - - - - - -
J1951 - Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg 0.25 MG 140.623 - - - - - -
J1952 - Leuprolide injectable, camcevi, 1 mg 1 mg 54.999 - - - - - -
J1953 - Injection, levetiracetam, 10 mg 10 MG 0.055 - - - - - -
J1954 - Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg 7.5 MG 257.704 - - - - - -
J1955 - Injection, levocarnitine, per 1 gm 1 GM 27.721 - - - - - -
J1956 - Injection, levofloxacin, 250 mg 250 MG 1.153 - - - - - -
J1961 - Injection, lenacapavir (only for use as hiv treatment), 1 mg 1 MG 21.993 - - - - - -
J2002 - Injection, lidocaine hcl in 5% dextrose, 1 mg 1 MG 0.003 - - - - - -
J2010 - Injection, lincomycin hcl, up to 300 mg 300 MG 9.356 - - - - - -
J2020 - Injection, linezolid, 200 mg 200 MG 3.08 - - - - - -
J2021 - Injection, linezolid (hospira), not therapeutically equivalent to j2020, 200 mg 200 MG 14.761 - - - - - -
J2060 - Injection, lorazepam, 2 mg 2 MG 1.456 - - - - - -
J2150 - Injection, mannitol, 25% in 50 ml 50 ML 2.609 - - - - - -
* 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