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 7 * 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
J1010 - Injection, methylprednisolone acetate, 1 mg 1 MG 0.119 - - - - - -
J1071 - Injection, testosterone cypionate, 1 mg 1 MG 0.032 - - - - - -
J1100 - Injection, dexamethasone sodium phosphate, 1 mg 1 MG 0.112 - - - - - -
J1110 - Injection, dihydroergotamine mesylate, per 1 mg 1 MG 48.077 - - - - - -
J1120 - Injection, acetazolamide sodium, up to 500 mg 500 MG 23.65 - - - - - -
J1160 - Injection, digoxin, up to 0.5 mg 0.5 MG 15.715 - - - - - -
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 4888.104 - - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.444 - - - - - -
J1171 - Injection, hydromorphone, 0.1 mg 0.1 MG 0.085 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 87.494 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.747 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 14.874 - - - - - -
J1203 - Injection, cipaglucosidase alfa-atga, 5 mg 5 MG 88.055 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 39.897 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 715.901 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 20.845 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.299 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.817 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 7.928 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.721 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.38 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 565.826 - - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 224.633 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 22.139 - - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 18.129 - - - - - -
* 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