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 7 * 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
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 108.006 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.804 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 15.073 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 121.346 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 680.82 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 19.671 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.951 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.718 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 9.848 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.772 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.378 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 539.327 - - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 225.685 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 21.815 - - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 17.766 - - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 221.773 - - - - - -
J1304 - Injection, tofersen, 1 mg 1 MG 150.838 - - - - - -
J1305 - Injection, evinacumab-dgnb, 5mg 5 MG 179.14 - - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.134 - - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 280.909 - - - - - -
J1325 - Injection, epoprostenol, 0.5 mg 0.5 MG 15.962 - - - - - -
J1335 - Injection, ertapenem sodium, 500 mg 500 MG 12.965 - - - - - -
J1364 - Injection, erythromycin lactobionate, per 500 mg 500 MG 80.775 - - - - - -
J1380 - Injection, estradiol valerate, up to 10 mg 10 MG 9.236 - - - - - -
J1410 - Injection, estrogen conjugated, per 25 mg 25 MG 372.146 - - - - - -
* 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