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 14 * 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
J2508 - Injection, pegunigalsidase alfa-iwxj, 1 mg 1 MG 223.547 - - - - - -
J2540 - Injection, penicillin g potassium, up to 600,000 units 600000 UNITS 1.013 - - - - - -
J2543 - Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 1.125 GM 1.102 - - - - - -
J2545 - Pentamidine isethionate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 300 mg 300 MG 85.531 - - - - - -
J2550 - Injection, promethazine hcl, up to 50 mg 50 MG 3.312 - - - - - -
J2560 - Injection, phenobarbital sodium, up to 120 mg 120 MG 31.378 - - - - - -
J2562 - Injection, plerixafor, 1 mg 1 MG 50.471 - - - - - -
J2597 - Injection, desmopressin acetate, per 1 mcg 1 MCG 5.42 - - - - - -
J2598 - Injection, vasopressin, 1 unit 1 UNIT 1.619 - - - - - -
J2599 - Injection, vasopressin (american regent), not therapeutically equivalent to j2598, 1 unit 1 UNIT 1.327 - - - - - -
J2675 - Injection, progesterone, per 50 mg 50 MG 0.726 - - - - - -
J2679 - Injection, fluphenazine hcl, 1.25 mg 1.25 MG 7.349 - - - - - -
J2680 - Injection, fluphenazine decanoate, up to 25 mg 25 MG 10.209 - - - - - -
J2690 - Injection, procainamide hcl, up to 1 gm 1 GM 546.066 - - - - - -
J2700 - Injection, oxacillin sodium, up to 250 mg 250 MG 0.867 - - - - - -
J2704 - Injection, propofol, 10 mg 10 MG 0.089 - - - - - -
J2720 - Injection, protamine sulfate, per 10 mg 10 MG 1.077 - - - - - -
J2724 - Injection, protein c concentrate, intravenous, human, 10 iu 10 UNITS 15.052 - - - - - -
J2760 - Injection, phentolamine mesylate, up to 5 mg 5 MG 367.121 - - - - - -
J2765 - Injection, metoclopramide hcl, up to 10 mg 10 MG 0.994 - - - - - -
J2777 - Injection, faricimab-svoa, 0.1 mg 0.1 MG 34.247 - - - - - -
J2778 - Injection, ranibizumab, 0.1 mg 0.1 mg 137.136 - - - - - -
J2779 - Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg 0.1 MG 79.08 - - - - - -
J2781 - Injection, pegcetacoplan, intravitreal, 1 mg 1 MG 147.356 - - - - - -
J2782 - Injection, avacincaptad pegol, 0.1 mg 0.1 MG 109.528 - - - - - -
* 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