HCPCS ·CODES

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 33 * 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
`Q5108` - Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg	0.5 MG	135.534	-	-	-	-	-	-
`Q5110` - Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram	1 MCG	0.27	-	-	-	-	-	-
`Q5111` - Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg	0.5 MG	143.377	-	-	-	-	-	-
`Q5112` - Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg	10 MG	34.165	-	-	-	-	-	-
`Q5113` - Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg	10 MG	60.437	-	-	-	-	-	-
`Q5114` - Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg	10 MG	54.158	-	-	-	-	-	-
`Q5115` - Injection, rituximab-abbs, biosimilar, (truxima), 10 mg	10 MG	33.594	-	-	-	-	-	-
`Q5116` - Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg	10 MG	19.17	-	-	-	-	-	-
`Q5117` - Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg	10 MG	24.332	-	-	-	-	-	-
`Q5118` - Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg	10 MG	23.586	-	-	-	-	-	-
`Q5119` - Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg	10 MG	22.437	-	-	-	-	-	-
`Q5121` - Injection, infliximab-axxq, biosimilar, (avsola), 10 mg	10 MG	21.29	-	-	-	-	-	-
`Q5122` - Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg	0.5 MG	96.548	-	-	-	-	-	-
`Q5123` - Injection, rituximab-arrx, biosimilar, (riabni), 10 mg	10 MG	38.645	-	-	-	-	-	-
`Q5124` - Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg	0.1 MG	170.799	-	-	-	-	-	-
`Q5125` - Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram	1 MCG	0.472	-	-	-	-	-	-
`Q5126` - Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg	10 MG	56.856	-	-	-	-	-	-
`Q5127` - Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg	0.5 MG	305.659	-	-	-	-	-	-
`Q5128` - Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg	0.1 MG	201.011	-	-	-	-	-	-
`Q5129` - Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg	10 MG	56.824	-	-	-	-	-	-
`Q5130` - Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg	0.5 MG	186.186	-	-	-	-	-	-
`Q9950` - Injection, sulfur hexafluoride lipid microspheres, per ml	1 ML	18.648	-	-	-	-	-	-
`Q9956` - Injection, octafluoropropane microspheres, per ml	1 ML	40.92	-	-	-	-	-	-
`Q9957` - Injection, perflutren lipid microspheres, per ml	1 ML	40.92	-	-	-	-	-	-
`Q9958` - High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml	1 ML	0.073	-	-	-	-	-	-
* 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