ASP Drug Pricing - (1st Quarter)
January 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2024 (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 12 * Effective January 1, 2025 through March 31, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J1952 - Leuprolide injectable, camcevi, 1 mg 1 mg 55.905 - - - - - -
J1953 - Injection, levetiracetam, 10 mg 10 MG 0.052 - - - - - -
J1954 - Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg 7.5 MG 235.28 - - - - - -
J1955 - Injection, levocarnitine, per 1 gm 1 GM 25.563 - - - - - -
J1956 - Injection, levofloxacin, 250 mg 250 MG 1.891 - - - - - -
J1961 - Injection, lenacapavir (only for use as hiv treatment), 1 mg 1 MG 21.982 - - - - - -
J2002 - Injection, lidocaine hcl in 5% dextrose, 1 mg 1 MG 0.003 - - - - - -
J2010 - Injection, lincomycin hcl, up to 300 mg 300 MG 6.727 - - - - - -
J2020 - Injection, linezolid, 200 mg 200 MG 2.979 - - - - - -
J2021 - Injection, linezolid (hospira), not therapeutically equivalent to j2020, 200 mg 200 MG 8.272 - - - - - -
J2060 - Injection, lorazepam, 2 mg 2 MG 1.351 - - - - - -
J2150 - Injection, mannitol, 25% in 50 ml 50 ML 2.536 - - - - - -
J2175 - Injection, meperidine hydrochloride, per 100 mg 100 MG 6.962 - - - - - -
J2182 - Injection, mepolizumab, 1 mg 1 MG 30.687 - - - - - -
J2183 - Injection, meropenem (wg critical care), not therapeutically equivalent to j2185, 100 mg 100 MG 1.654 - - - - - -
J2184 - Injection, meropenem (b. braun), not therapeutically equivalent to j2185, 100 mg 100 MG 2.074 - - - - - -
J2185 - Injection, meropenem, 100 mg 100 MG 0.388 - - - - - -
J2210 - Injection, methylergonovine maleate, up to 0.2 mg 0.2 MG 21.822 - - - - - -
J2247 - Injection, micafungin sodium (par pharm) not thereapeutically equivalent to j2248, 1 mg 1 MG 0.3087723288 - - - - - -
J2248 - Injection, micafungin sodium, 1 mg 1 MG 0.282 - - - - - -
J2250 - Injection, midazolam hydrochloride, per 1 mg 1 MG 0.131 - - - - - -
J2251 - Injection, midazolam in 0.9% sodium chloride, intravenous, not therapeutically equivalent to j2250, 1 mg 1 MG 0.165 - - - - - -
J2260 - Injection, milrinone lactate, 5 mg 5 MG 1.311 - - - - - -
J2267 - Injection, mirikizumab-mrkz, 1 mg 1 MG 45.393 - - - - - -
J2270 - Injection, morphine sulfate, up to 10 mg 10 MG 4.577 - - - - - -
* Effective January 1, 2025 through March 31, 2025

Drugs not otherwise classified - January 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2025 through March 31, 2025

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.33
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.783
Diltiazem Hydrochloride 5 MG 0.355
Doxycycline Hyclate 100 MG 12.599
Famotidine 10 MG 0.289
Flumazenil 0.1 MG 1.082
Folic Acid 5 MG 3.279
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 427.085
Metoprolol Tartrate 1 MG 0.128
Rifampin 600 MG 94.76
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.445
Sulfamethoxazole-Trimethoprim 400-80 MG 0.629

ASP (Average Sale Price) Drug Pricing History