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 9 * 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
J1460 - Injection, gamma globulin, intramuscular, 1 cc 1 CC 49.852 - - - - - -
J1551 - Injection, immune globulin (cutaquig), 100 mg 100 MG 14.498 - - - - - -
J1554 - Injection, immune globulin (asceniv), 500 mg 500 MG 491.404 - - - - - -
J1555 - Injection, immune globulin (cuvitru), 100 mg 100 MG 16.82 - - - - - -
J1556 - Injection, immune globulin (bivigam), 500 mg 500 MG 75.171 - - - - - -
J1557 - Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 57.925 - - - - - -
J1558 - Injection, immune globulin (xembify), 100 mg 100 MG 14.295 - - - - - -
J1559 - Injection, immune globulin (hizentra), 100 mg 100 MG 13.232 - - - - - -
J1560 - Injection, gamma globulin, intramuscular, over 10 cc 10 CC 498.522 - - - - - -
J1561 - Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg 500 MG 48.805 - - - - - -
J1566 - Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg 500 MG 82.192 - - - - - -
J1568 - Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 48.995 - - - - - -
J1569 - Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg 500 MG 49.692 - - - - - -
J1570 - Injection, ganciclovir sodium, 500 mg 500 MG 36.406 - - - - - -
J1571 - Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml 0.5 ML 68.657 - - - - - -
J1575 - Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin 100 MG 17.503 - - - - - -
J1576 - Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 67.461 - - - - - -
J1580 - Injection, garamycin, gentamicin, up to 80 mg 80 MG 2.74 - - - - - -
J1596 - Injection, glycopyrrolate, 0.1 mg 0.1 MG 0.51 - - - - - -
J1598 - Injection, glycopyrrolate (fresenius kabi), not therapeutically equivalent to j1596, 0.1 mg 0.1 MG 1.803 - - - - - -
J1602 - Injection, golimumab, 1 mg, for intravenous use 1 MG 11.1 - - - - - -
J1610 - Injection, glucagon hydrochloride, per 1 mg 1 MG 192.303 - - - - - -
J1611 - Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg 1 MG 108.925 - - - - - -
J1626 - Injection, granisetron hydrochloride, 100 mcg 100 MCG 0.281 - - - - - -
J1627 - Injection, granisetron, extended-release, 0.1 mg 0.1 MG 5.705 - - - - - -
* 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