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 13 * 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
J2327 - Injection, risankizumab-rzaa, intravenous, 1 mg 1 MG 14.632 - - - - - -
J2329 - Injection, ublituximab-xiiy, 1mg 1 MG 69.439 - - - - - -
J2350 - Injection, ocrelizumab, 1 mg 1 MG 59.798 - - - - - -
J2353 - Injection, octreotide, depot form for intramuscular injection, 1 mg 1 MG 214.884 - - - - - -
J2354 - Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg 25 MCG 0.863 - - - - - -
J2356 - Injection, tezepelumab-ekko, 1 mg 1 MG 18.109 - - - - - -
J2357 - Injection, omalizumab, 5 mg 5 MG 38.293 - - - - - -
J2358 - Injection, olanzapine, long-acting, 1 mg 1 MG 2.917 - - - - - -
J2359 - Injection, olanzapine, 0.5 mg 0.5 MG 0.916 - - - - - -
J2360 - Injection, orphenadrine citrate, up to 60 mg 60 MG 8.785 - - - - - -
J2372 - Injection, phenylephrine hydrochloride (biorphen), 20 micrograms 20 MCG 0.171 - - - - - -
J2373 - Injection, phenylephrine hydrochloride (immphentiv), 20 micrograms 20 MCG 0.153 - - - - - -
J2401 - Injection, chloroprocaine hydrochloride, per 1 mg 1 MG 0.028 - - - - - -
J2403 - Chloroprocaine hcl ophthalmic, 3% gel, 1 mg 1 MG 0.628 - - - - - -
J2404 - Injection, nicardipine, 0.1 mg 1 MG 0.539 - - - - - -
J2405 - Injection, ondansetron hydrochloride, per 1 mg 1 MG 0.089 - - - - - -
J2406 - Injection, oritavancin (kimyrsa), 10 mg 10 MG 42.503 - - - - - -
J2407 - Injection, oritavancin (orbactiv), 10 mg 10 MG 28.459 - - - - - -
J2426 - Injection, paliperidone palmitate extended release (invega sustenna), 1 mg 1 MG 14.762 - - - - - -
J2427 - Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg 1MG 12.657 - - - - - -
J2430 - Injection, pamidronate disodium, per 30 mg 30 MG 12.614 - - - - - -
J2469 - Injection, palonosetron hcl, 25 mcg 25 MCG 0.616 - - - - - -
J2501 - Injection, paricalcitol, 1 mcg 1 MCG 0.756 - - - - - -
J2506 - Injection, pegfilgrastim, excludes biosimilar, 0.5 mg 0.5 MG 31.144 - - - - - -
J2507 - Injection, pegloticase, 1 mg 1 MG 3482.154 - - - - - -
* 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