ASP Drug Pricing - (1st Quarter)
January 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2023 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 13 * Effective January 1, 2024 through March 31, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J2407 - Injection, oritavancin (orbactiv), 10 mg 10 MG 27.595 - - - - - -
J2426 - Injection, paliperidone palmitate extended release (invega sustenna), 1 mg 1 MG 14.318 - - - - - -
J2427 - Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg 1MG 12.21 - - - - - -
J2430 - Injection, pamidronate disodium, per 30 mg 30 MG 8.874 - - - - - -
J2469 - Injection, palonosetron hcl, 25 mcg 25 MCG 0.845 - - - - - -
J2501 - Injection, paricalcitol, 1 mcg 1 MCG 0.664854939048602 - - - - - -
J2506 - Injection, pegfilgrastim, excludes biosimilar, 0.5 mg 0.5 MG 50.678 - - - - - -
J2507 - Injection, pegloticase, 1 mg 1 MG 3371.076 - - - - - -
J2540 - Injection, penicillin g potassium, up to 600,000 units 600000 UNITS 0.771 - - - - - -
J2543 - Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 1.125 GM 1.177 - - - - - -
J2545 - Pentamidine isethionate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 300 mg 300 MG 52.22 - - - - - -
J2550 - Injection, promethazine hcl, up to 50 mg 50 MG 3.59 - - - - - -
J2560 - Injection, phenobarbital sodium, up to 120 mg 120 MG 31.432 - - - - - -
J2562 - Injection, plerixafor, 1 mg 1 MG 172.883 - - - - - -
J2597 - Injection, desmopressin acetate, per 1 mcg 1 MCG 6.328 - - - - - -
J2598 - Injection, vasopressin, 1 unit 1 UNIT 1.815 - - - - - -
J2599 - Injection, vasopressin (american regent), not therapeutically equivalent to j2598, 1 unit 1 UNIT 0.463 - - - - - -
J2675 - Injection, progesterone, per 50 mg 50 MG 0.914 - - - - - -
J2679 - Injection, fluphenazine hcl, 1.25 mg 1.25 MG 7.545 - - - - - -
J2680 - Injection, fluphenazine decanoate, up to 25 mg 25 MG 9.15 - - - - - -
J2690 - Injection, procainamide hcl, up to 1 gm 1 GM 146.317 - - - - - -
J2700 - Injection, oxacillin sodium, up to 250 mg 250 MG 1.048 - - - - - -
J2704 - Injection, propofol, 10 mg 10 MG 0.128 - - - - - -
J2720 - Injection, protamine sulfate, per 10 mg 10 MG 1.658 - - - - - -
J2724 - Injection, protein c concentrate, intravenous, human, 10 iu 10 UNITS 15.07 - - - - - -
* Effective January 1, 2024 through March 31, 2024

Drugs not otherwise classified - January 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2024 through March 31, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.29
Aztreonam 500 MG 14.778
Diltiazem Hydrochloride 5 MG 0.372
Doxycycline Hyclate 100 MG 15.942
Famotidine 10 MG 0.412
Flumazenil 0.1 MG 0.799
Folic Acid 5 MG 2.873
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Glycopyrrolate injection (Fresenius Kabi) 0.1 MG 2.698 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.144
Rifampin 600 MG 58.761
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.393
Sulfamethoxazole-Trimethoprim 400-80 MG 0.744

ASP (Average Sale Price) Drug Pricing History