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 24 * 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
J9176 - Injection, elotuzumab, 1 mg 1 MG 7.578 - - - - - -
J9177 - Injection, enfortumab vedotin-ejfv, 0.25 mg 0.25 MG 36.741 - - - - - -
J9178 - Injection, epirubicin hcl, 2 mg 2 MG 1.622 - - - - - -
J9179 - Injection, eribulin mesylate, 0.1 mg 0.1 MG 135.785 - - - - - -
J9181 - Injection, etoposide, 10 mg 10 MG 1.373 - - - - - -
J9185 - Injection, fludarabine phosphate, 50 mg 50 MG 134.154 - - - - - -
J9190 - Injection, fluorouracil, 500 mg 500 MG 2.394 - - - - - -
J9196 - Injection, gemcitabine hydrochloride (accord), not therapeutically equivalent to j9201, 200 mg 200 MG 8.523 - - - - - -
J9200 - Injection, floxuridine, 500 mg 500 MG 3858.031 - - - - - -
J9201 - Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg 200 MG 2.794 - - - - - -
J9202 - Goserelin acetate implant, per 3.6 mg 3.6 MG 674.772 - - - - - -
J9203 - Injection, gemtuzumab ozogamicin, 0.1 mg 0.1 MG 229.674 - - - - - -
J9204 - Injection, mogamulizumab-kpkc, 1 mg 1 MG 238.848 - - - - - -
J9205 - Injection, irinotecan liposome, 1 mg 1 MG 64.765 - - - - - -
J9206 - Injection, irinotecan, 20 mg 20 MG 2.498 - - - - - -
J9207 - Injection, ixabepilone, 1 mg 1 MG 134.057 - - - - - -
J9208 - Injection, ifosfamide, 1 gram 1 GM 24.924 - - - - - -
J9209 - Injection, mesna, 200 mg 200 MG 1.889 - - - - - -
J9210 - Injection, emapalumab-lzsg, 1 mg 1 MG 378.029 - - - - - -
J9211 - Injection, idarubicin hydrochloride, 5 mg 5 MG 46.712 - - - - - -
J9217 - Leuprolide acetate (for depot suspension), 7.5 mg 7.5 MG 176.51 - - - - - -
J9218 - Leuprolide acetate, per 1 mg 1 MG 9.204 - - - - - -
J9223 - Injection, lurbinectedin, 0.1 mg 0.1 MG 203.604 - - - - - -
J9226 - Histrelin implant (supprelin la), 50 mg 50 MG 45350.216 - - - - - -
J9227 - Injection, isatuximab-irfc, 10 mg 10 MG 78.049 - - - - - -
* 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