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 16 * 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
J3095 - Injection, telavancin, 10 mg 10 MG 6.377 - - - - - -
J3101 - Injection, tenecteplase, 1 mg 1 MG 157.724 - - - - - -
J3105 - Injection, terbutaline sulfate, up to 1 mg 1 MG 2.267 - - - - - -
J3111 - Injection, romosozumab-aqqg, 1 mg 1 MG 11.17 - - - - - -
J3121 - Injection, testosterone enanthate, 1 mg 1 MG 0.051 - - - - - -
J3145 - Injection, testosterone undecanoate, 1 mg 1 MG 1.946 - - - - - -
J3230 - Injection, chlorpromazine hcl, up to 50 mg 50 MG 27.71 - - - - - -
J3240 - Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial 0.9 MG 2073.341 - - - - - -
J3241 - Injection, teprotumumab-trbw, 10 mg 10 MG 343.885 - - - - - -
J3243 - Injection, tigecycline, 1 mg 1 MG 0.522 - - - - - -
J3245 - Injection, tildrakizumab, 1 mg 1 MG 135.923 - - - - - -
J3246 - Injection, tirofiban hcl, 0.25 mg 0.25 MG 3.826 - - - - - -
J3247 - Injection, secukinumab, intravenous, 1 mg 1 MG 17.541 - - - - - -
J3250 - Injection, trimethobenzamide hcl, up to 200 mg 200 MG 51.229 - - - - - -
J3260 - Injection, tobramycin sulfate, up to 80 mg 80 MG 2.27 - - - - - -
J3262 - Injection, tocilizumab, 1 mg 1 MG 5.962 - - - - - -
J3263 - Injection, toripalimab-tpzi, 1 mg 1 MG 38.867 - - - - - -
J3285 - Injection, treprostinil, 1 mg 1 MG 55.815 - - - - - -
J3299 - Injection, triamcinolone acetonide (xipere), 1 mg 1 MG 48.399 - - - - - -
J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg 10 MG 0.902 - - - - - -
J3304 - Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg 1 MG 17.746 - - - - - -
J3315 - Injection, triptorelin pamoate, 3.75 mg 3.75 MG 466.727 - - - - - -
J3357 - Ustekinumab, for subcutaneous injection, 1 mg 1 MG 159.913 - - - - - -
J3358 - Ustekinumab, for intravenous injection, 1 mg 1 MG 12.967 - - - - - -
J3360 - Injection, diazepam, up to 5 mg 5 MG 5.831 - - - - - -
* 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