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 25 * 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
J9228 - Injection, ipilimumab, 1 mg 1 MG 176.884 - - - - - -
J9229 - Injection, inotuzumab ozogamicin, 0.1 mg 0.1 MG 2618.847 - - - - - -
J9245 - Injection, melphalan hydrochloride, not otherwise specified, 50 mg 50 MG 153.536 - - - - - -
J9246 - Injection, melphalan (evomela), 1 mg 1 MG 17.351 - - - - - -
J9260 - Injection, methotrexate sodium, 50 mg 50 MG 2.723 - - - - - -
J9261 - Injection, nelarabine, 50 mg 50 MG 72.527 - - - - - -
J9263 - Injection, oxaliplatin, 0.5 mg 0.5 MG 0.062 - - - - - -
J9264 - Injection, paclitaxel protein-bound particles, 1 mg 1 MG 13.344 - - - - - -
J9266 - Injection, pegaspargase, per single dose vial 1 EA 27070.534 - - - - - -
J9267 - Injection, paclitaxel, 1 mg 1 MG 0.101 - - - - - -
J9268 - Injection, pentostatin, 10 mg 10 MG 2541.774 - - - - - -
J9269 - Injection, tagraxofusp-erzs, 10 micrograms 10 MCG 339.034 - - - - - -
J9271 - Injection, pembrolizumab, 1 mg 1 MG 58.216 - - - - - -
J9272 - Injection, dostarlimab-gxly, 10 mg 10 MG 236.402 - - - - - -
J9273 - Injection, tisotumab vedotin-tftv, 1 mg 1 MG 181.598 - - - - - -
J9274 - Injection, tebentafusp-tebn, 1 microgram 1 MCG 214.756 - - - - - -
J9280 - Injection, mitomycin, 5 mg 5 MG 42.505 - - - - - -
J9281 - Mitomycin pyelocalyceal instillation, 1 mg 1 MG 307.342 - - - - - -
J9286 - Injection, glofitamab-gxbm, 2.5 mg 2.5 MG 2701.038 - - - - - -
J9293 - Injection, mitoxantrone hydrochloride, per 5 mg 5 MG 54.651 - - - - - -
J9294 - Injection, pemetrexed (hospira), not therapeutically equivalent to j9305, 10 mg 10 MG 0.618 - - - - - -
J9295 - Injection, necitumumab, 1 mg 1 MG 5.731 - - - - - -
J9297 - Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg 10 MG 1.284 - - - - - -
J9298 - Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg 3 mg/1 mg 190.461 - - - - - -
J9299 - Injection, nivolumab, 1 mg 1 MG 31.75 - - - - - -
* 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