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 13 * 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
J2272 - Injection, morphine sulfate (fresenius kabi), not therapeutically equivalent to j2270, up to 10 mg 10 MG 4.057 - - - - - -
J2274 - Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 10 MG 11.55 - - - - - -
J2277 - Injection, motixafortide, 0.25 mg 0.25 MG 25.218 - - - - - -
J2278 - Injection, ziconotide, 1 microgram 1 MCG 9.778 - - - - - -
J2280 - Injection, moxifloxacin, 100 mg 100 MG 8.648 - - - - - -
J2281 - Injection, moxifloxacin (fresenius kabi), not therapeutically equivalent to j2280, 100 mg 100 MG 6.166 - - - - - -
J2300 - Injection, nalbuphine hydrochloride, per 10 mg 10 MG 3.427 - - - - - -
J2305 - Injection, nitroglycerin, 5 mg 5 MG 1.41 - - - - - -
J2310 - Injection, naloxone hydrochloride, per 1 mg 1 MG 8.702 - - - - - -
J2311 - Injection, naloxone hydrochloride (zimhi), 1 mg 1 MG 1.495 - - - - - -
J2315 - Injection, naltrexone, depot form, 1 mg 1 MG 4.123 - - - - - -
J2323 - Injection, natalizumab, 1 mg 1 MG 23.88 - - - - - -
J2327 - Injection, risankizumab-rzaa, intravenous, 1 mg 1 MG 15.081 - - - - - -
J2329 - Injection, ublituximab-xiiy, 1mg 1 MG 69.025 - - - - - -
J2350 - Injection, ocrelizumab, 1 mg 1 MG 58.766 - - - - - -
J2353 - Injection, octreotide, depot form for intramuscular injection, 1 mg 1 MG 218.371 - - - - - -
J2354 - Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg 25 MCG 0.805 - - - - - -
J2356 - Injection, tezepelumab-ekko, 1 mg 1 MG 18.155 - - - - - -
J2357 - Injection, omalizumab, 5 mg 5 MG 37.755 - - - - - -
J2358 - Injection, olanzapine, long-acting, 1 mg 1 MG 2.917 - - - - - -
J2359 - Injection, olanzapine, 0.5 mg 0.5 MG 0.745 - - - - - -
J2360 - Injection, orphenadrine citrate, up to 60 mg 60 MG 13.994 - - - - - -
J2372 - Injection, phenylephrine hydrochloride (biorphen), 20 micrograms 20 MCG 0.167 - - - - - -
J2373 - Injection, phenylephrine hydrochloride (immphentiv), 20 micrograms 20 MCG 0.139 - - - - - -
J2401 - Injection, chloroprocaine hydrochloride, per 1 mg 1 MG 0.031 - - - - - -
* 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