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 20 * 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
J7326 - Hyaluronan or derivative, gel-one, for intra-articular injection, per dose per dose 534.483 - - - - - -
J7327 - Hyaluronan or derivative, monovisc, for intra-articular injection, per dose PER DOSE 683.165 - - - - - -
J7328 - Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg 0.1 MG 0.576 - - - - - -
J7329 - Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg 1 MG 6.665 - - - - - -
J7331 - Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg 1 MG 9.575 - - - - - -
J7332 - Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg 1 MG 10.356 - - - - - -
J7336 - Capsaicin 8% patch, per square centimeter 1 SQ CM 3.325 - - - - - -
J7340 - Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml 100 ML 235.06 - - - - - -
J7345 - Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg 10 MG 1.724 - - - - - -
J7351 - Injection, bimatoprost, intracameral implant, 1 microgram 1 MCG 209.861 - - - - - -
J7354 - Cantharidin for topical administration, 0.7%, single unit dose applicator (3.2 mg) Per 3.2 mg single-use applicator 711.753 - - - - - -
J7402 - Mometasone furoate sinus implant, (sinuva), 10 micrograms 10 MCG 11.345 - - - - - -
J7500 - Azathioprine, oral, 50 mg 50 MG 1.616 - - - - - -
J7502 - Cyclosporine, oral, 100 mg 100 MG 2.387 - - - - - -
J7503 - Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg 0.25 MG 1.767 - - - - - -
J7504 - Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg 250 MG 3968.446 - - - - - -
J7507 - Tacrolimus, immediate release, oral, 1 mg 1 MG 0.255 - - - - - -
J7508 - Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg 0.1 MG 0.567 - - - - - -
J7509 - Methylprednisolone oral, per 4 mg 4 MG 0.244 - - - - - -
J7510 - Prednisolone oral, per 5 mg 5 MG 0.386 - - - - - -
J7511 - Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg 25 MG 956.739 - - - - - -
J7512 - Prednisone, immediate release or delayed release, oral, 1 mg 1 MG 0.005 - - - - - -
J7515 - Cyclosporine, oral, 25 mg 25 MG 0.847 - - - - - -
J7517 - Mycophenolate mofetil, oral, 250 mg 250 MG 0.175 - - - - - -
J7518 - Mycophenolic acid, oral, 180 mg 180 MG 0.442 - - - - - -
* 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