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 4 * 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
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 6.406 - - - - - -
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.63 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 12.989 - - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.338 - - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 4.026 - - - - - -
J0594 - injection, busulfan, 1 mg 1 MG 1.27 - - - - - -
J0595 - Injection, butorphanol tartrate, 1 mg 1 MG 4.061 - - - - - -
J0596 - Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units 10 UNITS 34.724 - - - - - -
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 68.362 - - - - - -
J0598 - Injection, c-1 esterase inhibitor (human), cinryze, 10 units 10 UNITS 64.212 - - - - - -
J0612 - Injection, calcium gluconate, not otherwise specified, 10 mg 10 MG 0.039 - - - - - -
J0613 - Injection, calcium gluconate (wg critical care), not therapeutically equivalent to j0612, 10 mg 10 MG 0.088 - - - - - -
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 1173.059 - - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 6.32 - - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 127.81 - - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 4.07 - - - - - -
J0641 - Injection, levoleucovorin, not otherwise specified, 0.5 mg 0.5 MG 0.206 - - - - - -
J0642 - Injection, levoleucovorin (khapzory), 0.5 mg 0.5 MG 1.375 - - - - - -
J0665 - Injection, bupivicaine, not otherwise specified, 0.5 mg 0.5 MG 0.011 - - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.488 - - - - - -
J0687 - Injection, cefazolin sodium (wg critical care), not therapeutically equivalent to j0690, 500 mg 500 MG 1.036 - - - - - -
J0688 - Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg 500 MG 0.984 - - - - - -
J0689 - Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg 500 MG 1.26 - - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.805 - - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.217 - - - - - -
* 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