• 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 2 * 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
J0177 - Injection, aflibercept hd, 1 mg 1 MG 333.696 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 821.98 - - - - - -
J0179 - Injection, brolucizumab-dbll, 1 mg 1 MG 332.565 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 223.522 - - - - - -
J0185 - Injection, aprepitant, 1 mg 1 MG 1.765 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 2337.693 - - - - - -
J0206 - Injection, allopurinol sodium, 1 mg 1 MG 5.003 - - - - - -
J0217 - Injection, velmanase alfa-tycv, 1 mg 1 MG 442.004 - - - - - -
J0218 - Injection, olipudase alfa-rpcp, 1 mg 1 MG 382.56 - - - - - -
J0219 - Injection, avalglucosidase alfa-ngpt, 4 mg 4 MG 77.752 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 201.965 - - - - - -
J0222 - Injection, patisiran, 0.1 mg 0.1 MG 98.879 - - - - - -
J0223 - Injection, givosiran, 0.5 mg 0.5 MG 112.135 - - - - - -
J0224 - Injection, lumasiran, 0.5 mg 0.5 MG 317.878 - - - - - -
J0225 - Injection, vutrisiran, 1 mg 1 MG 4926.002 - - - - - -
J0248 - Injection, remdesivir, 1 mg 1 MG 6.354 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.935 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 5.576 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 0.769 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 6.481 - - - - - -
J0283 - Injection, amiodarone hydrochloride (nexterone), 30 mg 30 MG 2.544 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 48.957 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 23.325 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.784 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.593 - - - - - -
* 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