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 23 * 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
J9049 - Injection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg 0.1 MG 1.494 - - - - - -
J9050 - Injection, carmustine, 100 mg 100 MG 330.871 - - - - - -
J9055 - Injection, cetuximab, 10 mg 10 MG 75.479 - - - - - -
J9056 - Injection, bendamustine hydrochloride (vivimusta), 1 mg 1 MG 27.844 - - - - - -
J9058 - Injection, bendamustine hydrochloride (apotex), 1 mg 1 MG 15.217 - - - - - -
J9059 - Injection, bendamustine hydrochloride (baxter), 1 mg 1 MG 15.217 - - - - - -
J9060 - Injection, cisplatin, powder or solution, 10 mg 10 MG 2.371 - - - - - -
J9061 - Injection, amivantamab-vmjw, 2 mg 2 MG 20.673 - - - - - -
J9063 - Injection, mirvetuximab soravtansine-gynx, 1 mg 1 MG 66.758 - - - - - -
J9065 - Injection, cladribine, per 1 mg 1 MG 14.245 - - - - - -
J9071 - Injection, cyclophosphamide (auromedics), 5 mg 5 MG 1.16 - - - - - -
J9073 - Injection, cyclophosphamide (dr. reddy's), 5 mg 5 MG 0.925 - - - - - -
J9075 - Injection, cyclophosphamide, not otherwise specified, 5 mg 5 MG 1.01 - - - - - -
J9100 - Injection, cytarabine, 100 mg 100 MG 0.771 - - - - - -
J9118 - Injection, calaspargase pegol-mknl, 10 units 10 UNIT 76.527 - - - - - -
J9119 - Injection, cemiplimab-rwlc, 1 mg 1 MG 28.24 - - - - - -
J9120 - Injection, dactinomycin, 0.5 mg 0.5 MG 282.133 - - - - - -
J9130 - Dacarbazine, 100 mg 100 MG 4.269 - - - - - -
J9144 - Injection, daratumumab, 10 mg and hyaluronidase-fihj 10 MG 51.411 - - - - - -
J9145 - Injection, daratumumab, 10 mg 10 MG 65.117 - - - - - -
J9150 - Injection, daunorubicin, 10 mg 10 MG 24.436 - - - - - -
J9153 - Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine 1 MG/2.27 MG 242.495 - - - - - -
J9155 - Injection, degarelix, 1 mg 1 MG 4.176 - - - - - -
J9171 - Injection, docetaxel, 1 mg 1 MG 0.791 - - - - - -
J9173 - Injection, durvalumab, 10 mg 10 MG 81.815 - - - - - -
* 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