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 5 * 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
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 4.51 - - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 8.23 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.444 - - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 1.884 - - - - - -
J0699 - Injection, cefiderocol, 10 mg 10 mg 2.282 - - - - - -
J0701 - Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.833 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 7.399 - - - - - -
J0703 - Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg 500 MG 4.973 - - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.935 - - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 1.66 - - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 100.582 - - - - - -
J0717 - Injection, certolizumab pegol, 1 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) 1 MG 4.652 - - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 19.184 - - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 18.37 - - - - - -
J0736 - Injection, clindamycin phosphate, 300 mg 300 MG 2.465 - - - - - -
J0737 - Injection, clindamycin phosphate (baxter), not therapeutically equivalent to j0736, 300 mg 300 MG 2.815 - - - - - -
J0739 - Injection, cabotegravir, 1mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv) 1 mg N/A - - - - - -
J0740 - Injection, cidofovir, 375 mg 375 MG 528.002 - - - - - -
J0741 - Injection, cabotegravir and rilpivirine, 2mg/3mg 2MG/3MG 22.901 - - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.512 - - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 6.956 - - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 1.858 - - - - - -
J0750 - Emtricitabine 200mg and tenofovir disoproxil fumarate 300mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv) 200 mg/300 mg N/A - - - - - -
J0751 - Emtricitabine 200mg and tenofovir alafenamide 25mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv) 200 mg/25 mg N/A - - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 12.282 - - - - - -
* 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