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 3 * 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
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.017 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.459 - - - - - -
J0349 - Injection, rezafungin, 1 mg 1 MG 10.121 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 4.04 - - - - - -
J0401 - Injection, aripiprazole (abilify maintena), 1 mg 1 MG 7.074 - - - - - -
J0402 - Injection, aripiprazole (abilify asimtufii), 1 mg 1 MG 5.947 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 2.059 - - - - - -
J0457 - Injection, aztreonam, 100 mg 100 MG 1.974 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.108 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 174.581 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 43.552 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4588.77 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.812 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 54.149 - - - - - -
J0491 - Injection, anifrolumab-fnia, 1 mg 1 MG 17.291 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 15.874 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 16.562 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 167.297 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 19.523 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 24.368 - - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.863 - - - - - -
J0577 - Injection, buprenorphine extended-release (brixadi), less than or equal to 7 days of therapy Less than or equal to 7 days of therapy 429.156 - - - - - -
J0578 - Injection, buprenorphine extended release (brixadi), greater than 7 days and up to 28 days of therapy Greater than 7 days and up to 28 days of therapy 1716.623 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 0.167 - - - - - -
J0584 - Injection, burosumab-twza 1 mg 1 MG 469.576 - - - - - -
* 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