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 18 * 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
J7070 - Infusion, d5w, 1000 cc 1000 CC 3.647 - - - - - -
J7120 - Ringers lactate infusion, up to 1000 cc 1000 CC 2.42 - - - - - -
J7170 - Injection, emicizumab-kxwh, 0.5 mg 0.5 MG 52.82 - - - - - - 1
J7171 - Injection, adamts13, recombinant-krhn, 10 iu 10 UNITS 34.597 - - - - - -
J7175 - Injection, factor x, (human), 1 i.u. 1 IU 9.112 - - - - - - 1
J7177 - Injection, human fibrinogen concentrate (fibryga), 1 mg 1 MG 1.112 - - - - - - 1
J7178 - Injection, human fibrinogen concentrate, not otherwise specified, 1 mg 1 MG 1.446 - - - - - - 1
J7179 - Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco 1 IU 1.871 - - - - - - 1
J7180 - Injection, factor xiii (antihemophilic factor, human), 1 i.u. 1 IU 10.159 - - - - - - 1
J7181 - Injection, factor xiii a-subunit, (recombinant), per iu 1 IU 17.256 - - - - - - 1
J7182 - Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu 1 IU 1.378 - - - - - - 1
J7183 - Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco 1 I.U. VWF:RCO 1.28 - - - - - - 1
J7185 - Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. 1 IU 1.483 - - - - - - 1
J7186 - Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. PER FACTOR VIII IU 1.225 - - - - - - 1
J7187 - Injection, von willebrand factor complex (humate-p), per iu vwf:rco 1 IU 1.395 - - - - - - 1
J7188 - Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. 1 IU 3.221 - - - - - - 1
J7189 - Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram 1 MCG 2.517 - - - - - - 1
J7190 - Factor viii (antihemophilic factor, human) per i.u. 1 IU 1.171 - - - - - - 1
J7192 - Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified 1 IU 1.548 - - - - - - 1
J7193 - Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. 1 IU 1.409 - - - - - - 1
J7194 - Factor ix, complex, per i.u. 1 IU 1.652 - - - - - - 1
J7195 - Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified 1 IU 1.852 - - - - - - 1
J7197 - Antithrombin iii (human), per i.u. 1 IU 3.853 - - - - - -
J7198 - Anti-inhibitor, per i.u. 1 IU 2.344 - - - - - - 1
J7200 - Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu 1 IU 1.674 - - - - - - 1
* 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