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 27 * 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
J9348 - Injection, naxitamab-gqgk, 1 mg 1 MG 642.146 - - - - - -
J9349 - Injection, tafasitamab-cxix, 2 mg 2 MG 13.709 - - - - - -
J9350 - Injection, mosunetuzumab-axgb, 1 mg 1 MG 635.465 - - - - - -
J9351 - Injection, topotecan, 0.1 mg 0.1 MG 1.619 - - - - - -
J9352 - Injection, trabectedin, 0.1 mg 0.1 MG 362.824 - - - - - -
J9353 - Injection, margetuximab-cmkb, 5 mg 5 MG 48.208 - - - - - -
J9354 - Injection, ado-trastuzumab emtansine, 1 mg 1 MG 40.445 - - - - - -
J9355 - Injection, trastuzumab, excludes biosimilar, 10 mg 10 MG 77.94 - - - - - -
J9356 - Injection, trastuzumab, 10 mg and hyaluronidase-oysk 10 MG 63.787 - - - - - -
J9357 - Injection, valrubicin, intravesical, 200 mg 200 MG 1437.078 - - - - - -
J9358 - Injection, fam-trastuzumab deruxtecan-nxki, 1 mg 1 MG 27.811 - - - - - -
J9359 - Injection, loncastuximab tesirine-lpyl, 0.075 mg 0.075 MG 206.375 - - - - - -
J9360 - Injection, vinblastine sulfate, 1 mg 1 MG 4.433 - - - - - -
J9370 - Vincristine sulfate, 1 mg 1 MG 8.213 - - - - - -
J9380 - Injection, teclistamab-cqyv, 0.5 mg 0.5 MG 31.98 - - - - - -
J9381 - Injection, teplizumab-mzwv, 5 mcg 5 MCG 36.904 - - - - - -
J9390 - Injection, vinorelbine tartrate, 10 mg 10 MG 7.593 - - - - - -
J9394 - Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg 25 MG 53 - - - - - -
J9395 - Injection, fulvestrant, 25 mg 25 MG 7.506 - - - - - -
J9400 - Injection, ziv-aflibercept, 1 mg 1 MG 6.504 - - - - - -
P9041 - Infusion, albumin (human), 5%, 50 ml 50 ML 10.615 - - - - 95% 10.615
P9045 - Infusion, albumin (human), 5%, 250 ml 250 ML 53.077 - - - - 95% 53.077
P9046 - Infusion, albumin (human), 25%, 20 ml 20 ML 21.231 - - - - 95% 21.231
P9047 - Infusion, albumin (human), 25%, 50 ml 50 ML 53.077 - - - - 95% 53.077
Q0138 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) 1 MG 0.338 - - - - - -
* 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