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 17 * 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
J3370 - Injection, vancomycin hcl, 500 mg 500 MG 2.164 - - - - - -
J3371 - Injection, vancomycin hcl (mylan), not therapeutically equivalent to j3370, 500 mg 500 MG 5.672 - - - - - -
J3372 - Injection, vancomycin hcl (xellia), not therapeutically equivalent to j3370, 500 mg 500 MG 6.417 - - - - - -
J3380 - Injection, vedolizumab, intravenous, 1 mg 1 MG 22.26 - - - - - -
J3385 - Injection, velaglucerase alfa, 100 units 100 UNITS 370.2 - - - - - -
J3396 - Injection, verteporfin, 0.1 mg 0.1 MG 11.534 - - - - - -
J3401 - Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml 0.1 ML 996.961 - - - - - -
J3410 - Injection, hydroxyzine hcl, up to 25 mg 25 MG 12.405 - - - - - -
J3411 - Injection, thiamine hcl, 100 mg 100 MG 1.786 - - - - - -
J3415 - Injection, pyridoxine hcl, 100 mg 100 MG 17.643 - - - - - -
J3420 - Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 1000 MCG 1.149 - - - - - -
J3425 - Injection, hydroxocobalamin, intramuscular, 10 mcg 10 MCG 0.008 - - - - - -
J3430 - Injection, phytonadione (vitamin k), per 1 mg 1 MG 2.511 - - - - - -
J3465 - Injection, voriconazole, 10 mg 10 MG 0.776 - - - - - -
J3473 - Injection, hyaluronidase, recombinant, 1 usp unit 1 USP UNIT 0.365 - - - - - -
J3475 - Injection, magnesium sulfate, per 500 mg 500 MG 0.467 - - - - - -
J3480 - Injection, potassium chloride, per 2 meq 2 MEQ 0.105 - - - - - -
J3485 - Injection, zidovudine, 10 mg 10 MG 1.512 - - - - - -
J3486 - Injection, ziprasidone mesylate, 10 mg 10 MG 7.432 - - - - - -
J3489 - Injection, zoledronic acid, 1 mg 1 MG 6.472 - - - - - -
J7030 - Infusion, normal saline solution , 1000 cc 1000 CC 2.567 - - - - - -
J7040 - Infusion, normal saline solution, sterile (500 ml = 1 unit) 500 ML 1.283 - - - - - -
J7042 - 5% dextrose/normal saline (500 ml = 1 unit) 500 ML 1.142 - - - - - -
J7050 - Infusion, normal saline solution, 250 cc 250 CC 0.642 - - - - - -
J7060 - 5% dextrose/water (500 ml = 1 unit) 500 ML 1.824 - - - - - -
* 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