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 1 * 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
A9573 - Injection, gadopiclenol, 1 ml 1 ML 4.168 - - - - - -
A9575 - Injection, gadoterate meglumine, 0.1 ml 0.1 ML 0.117 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.468 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.815 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.794 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.492 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.733 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.274 - - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1366.361 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 3.802 - - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.209 - - - - - -
J0129 - Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 10 MG 43.437 - - - - - -
J0131 - Injection, acetaminophen, not otherwise specified,10 mg 10 MG 0.041 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 0.569 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.026 - - - - - -
J0134 - Injection, acetaminophen (fresenius kabi), not therapeutically equivalent to j0131, 10 mg 10 MG 0.041 - - - - - -
J0136 - Injection, acetaminophen (b braun), not therapeutically equivalent to j0131, 10 mg 10 MG 0.048 - - - - - -
J0137 - Injection, acetaminophen (hikma), not therapeutically equivalent to j0131, 10 mg 10 MG 0.053 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.397 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.825 - - - - - -
J0172 - Injection, aducanumab-avwa, 2 mg 2 MG 5.978 - - - - - -
J0173 - Injection, epinephrine (belcher), not therapeutically equivalent to j0171, 0.1 mg 0.1 MG 2.009 - - - - - -
J0174 - Lecanemab-irmb, for intravenous injection, 1 mg 1 MG 1.336 - - - - - -
J0175 - Injection, donanemab-azbt, 2 mg 2 MG 4.094 - - - - - -
* 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