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 8 * 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
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 220.752 - - - - - -
J1304 - Injection, tofersen, 1 mg 1 MG 153.664 - - - - - -
J1305 - Injection, evinacumab-dgnb, 5mg 5 MG 186.306 - - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.185 - - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 293.916 - - - - - -
J1323 - Injection, elranatamab-bcmm, 1 mg 1 MG 178.848 - - - - - -
J1325 - Injection, epoprostenol, 0.5 mg 0.5 MG 15.86 - - - - - -
J1335 - Injection, ertapenem sodium, 500 mg 500 MG 10.416 - - - - - -
J1364 - Injection, erythromycin lactobionate, per 500 mg 500 MG 65.379 - - - - - -
J1380 - Injection, estradiol valerate, up to 10 mg 10 MG 7.505 - - - - - -
J1410 - Injection, estrogen conjugated, per 25 mg 25 MG 382.786 - - - - - -
J1430 - Injection, ethanolamine oleate, 100 mg 100 MG 491.684 - - - - - -
J1437 - Injection, ferric derisomaltose, 10 mg 10 MG 21.052 - - - - - -
J1439 - Injection, ferric carboxymaltose, 1 mg 1 MG 1.101 - - - - - -
J1440 - Fecal microbiota, live - jslm, 1 ml 1 ML 63.3 - - - - - -
J1442 - Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram 1 MCG 0.995 - - - - - -
J1447 - Injection, tbo-filgrastim, 1 microgram 1 MCG 0.388 - - - - - -
J1448 - Injection, trilaciclib, 1mg 1 MG 5.362 - - - - - -
J1449 - Injection, eflapegrastim-xnst, 0.1 mg 0.1 MG 22.754 - - - - - -
J1450 - Injection fluconazole, 200 mg 200 MG 2.612 - - - - - -
J1453 - Injection, fosaprepitant, 1 mg 1 MG 0.136 - - - - - -
J1454 - Injection, fosnetupitant 235 mg and palonosetron 0.25 mg 0.25 MG 679.51 - - - - - -
J1456 - Injection, fosaprepitant (teva), not therapeutically equivalent to j1453, 1 mg 1 MG 2.043 - - - - - -
J1458 - Injection, galsulfase, 1 mg 1 MG 484.752 - - - - - -
J1459 - Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 48.579 - - - - - -
* 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