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 26 * 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
J9301 - Injection, obinutuzumab, 10 mg 10 MG 74.588 - - - - - -
J9303 - Injection, panitumumab, 10 mg 10 MG 159.326 - - - - - -
J9304 - Injection, pemetrexed (pemfexy), 10 mg 10 MG 50.83 - - - - - -
J9305 - Injection, pemetrexed, not otherwise specified, 10 mg 10 MG 4.184 - - - - - -
J9306 - Injection, pertuzumab, 1 mg 1 MG 16.118 - - - - - -
J9307 - Injection, pralatrexate, 1 mg 1 MG 373.768 - - - - - -
J9308 - Injection, ramucirumab, 5 mg 5 MG 71.071 - - - - - -
J9309 - Injection, polatuzumab vedotin-piiq, 1 mg 1 MG 129.781 - - - - - -
J9311 - Injection, rituximab 10 mg and hyaluronidase 10 mg 36.942 - - - - - -
J9312 - Injection, rituximab, 10 mg 10 MG 77.314 - - - - - -
J9314 - Injection, pemetrexed (teva), not therapeutically equivalent to j9305, 10 mg 10 MG 5.519 - - - - - -
J9316 - Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg 10 MG 64.576 - - - - - -
J9317 - Injection, sacituzumab govitecan-hziy, 2.5 mg 2.5 MG 34.668 - - - - - -
J9319 - Injection, romidepsin, lyophilized, 0.1 mg 0.1 MG 29.863 - - - - - -
J9321 - Injection, epcoritamab-bysp, 0.16 mg 0.16 MG 54.169 - - - - - -
J9325 - Injection, talimogene laherparepvec, per 1 million plaque forming units 1 million PFU 70.361 - - - - - -
J9328 - Injection, temozolomide, 1 mg 1 MG 10.398 - - - - - -
J9330 - Injection, temsirolimus, 1 mg 1 MG 32.21 - - - - - -
J9331 - Injection, sirolimus protein-bound particles, 1 mg 1 MG 114.205 - - - - - -
J9332 - Injection, efgartigimod alfa-fcab, 2mg 2 MG 32.569 - - - - - -
J9333 - Injection, rozanolixizumab-noli, 1 mg 1 MG 22.797 - - - - - -
J9334 - Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc 2 MG 33.128 - - - - - -
J9340 - Injection, thiotepa, 15 mg 15 MG 209.016 - - - - - -
J9345 - Injection, retifanlimab-dlwr, 1 mg 1 MG 29.199 - - - - - -
J9347 - Injection, tremelimumab-actl, 1 mg 1 MG 135.448 - - - - - -
* 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