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 6 * 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
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 71.159 - - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 3.661 - - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 128.538 - - - - - -
J0801 - Injection, corticotropin (acthar gel), up to 40 units 40 UNITS 3750.08 - - - - - -
J0802 - Injection, corticotropin (ani), up to 40 units up to 40 Units 3416.971 - - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 25.089 - - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 1762.348 - - - - - -
J0841 - Injection, crotalidae immune f(ab')2 (equine), 120 mg 120 MG 1040.114 - - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1814.938 - - - - - -
J0872 - Injection, daptomycin (xellia), unrefrigerated, not therapeutically equivalent to j0878 or j0873, 1 mg 1 MG 0.041 - - - - - -
J0873 - Injection, daptomycin (xellia), not therapeutically equivalent to j0878 or j0872, 1 mg 1 MG 0.041 - - - - - -
J0874 - Injection, daptomycin (baxter), not therapeutically equivalent to j0878, 1 mg 1 MG 0.068 - - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 15.612 - - - - - -
J0877 - Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg 1 MG 0.056 - - - - - -
J0878 - Injection, daptomycin, 1 mg 1 MG 0.032 - - - - - -
J0881 - Injection, darbepoetin alfa, 1 microgram (non-esrd use) 1 MCG 3.036 - - - - - -
J0882 - Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) 1 MCG 3.036 - - - - - -
J0885 - Injection, epoetin alfa, (for non-esrd use), 1000 units 1000 UNITS 7.528 - - - - - -
J0887 - Injection, epoetin beta, 1 microgram, (for esrd on dialysis) 1 MCG 1.211 - - - - - -
J0888 - Injection, epoetin beta, 1 microgram, (for non esrd use) 1 MCG 1.157 - - - - - -
J0894 - Injection, decitabine, 1 mg 1 MG 1.63 - - - - - -
J0895 - Injection, deferoxamine mesylate, 500 mg 500 MG 6.778 - - - - - -
J0896 - Injection, luspatercept-aamt, 0.25 mg 0.25 MG 40.615 - - - - - -
J0897 - Injection, denosumab, 1 mg 1 MG 26.96 - - - - - -
J1000 - Injection, depo-estradiol cypionate, up to 5 mg 5 MG 38.653 - - - - - -
* 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