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 34 * 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
`Q9963` - High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml	1 ML	0.217	-	-	-	-	-	-
`Q9965` - Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml	1 ML	1.555	-	-	-	-	-	-
`Q9966` - Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml	1 ML	0.379	-	-	-	-	-	-
`Q9967` - Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml	1 ML	0.141	-	-	-	-	-	-
`Q9991` - Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg	Less than or equal to 100 MG	1943.058	-	-	-	-	-	-
`Q9992` - Injection, buprenorphine extended-release (sublocade), greater than 100 mg	Greater than 100 MG	1943.058	-	-	-	-	-	-
* 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
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