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 15 * 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
J2679 - Injection, fluphenazine hcl, 1.25 mg 1.25 MG 7.693 - - - - - -
J2680 - Injection, fluphenazine decanoate, up to 25 mg 25 MG 9.41 - - - - - -
J2690 - Injection, procainamide hcl, up to 1 gm 1 GM 183.031 - - - - - -
J2700 - Injection, oxacillin sodium, up to 250 mg 250 MG 1.065 - - - - - -
J2704 - Injection, propofol, 10 mg 10 MG 0.083 - - - - - -
J2720 - Injection, protamine sulfate, per 10 mg 10 MG 1.143 - - - - - -
J2724 - Injection, protein c concentrate, intravenous, human, 10 iu 10 UNITS 15.031 - - - - - -
J2760 - Injection, phentolamine mesylate, up to 5 mg 5 MG 394.625 - - - - - -
J2765 - Injection, metoclopramide hcl, up to 10 mg 10 MG 1.031 - - - - - -
J2777 - Injection, faricimab-svoa, 0.1 mg 0.1 MG 35.246 - - - - - -
J2778 - Injection, ranibizumab, 0.1 mg 0.1 mg 123.979 - - - - - -
J2779 - Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg 0.1 MG 80.46 - - - - - -
J2781 - Injection, pegcetacoplan, intravitreal, 1 mg 1 MG 146.367 - - - - - -
J2782 - Injection, avacincaptad pegol, 0.1 mg 0.1 MG 108.704 - - - - - -
J2783 - Injection, rasburicase, 0.5 mg 0.5 MG 369.967 - - - - - -
J2785 - Injection, regadenoson, 0.1 mg 0.1 MG 3.811 - - - - - -
J2786 - Injection, reslizumab, 1 mg 1 MG 10.319 - - - - - -
J2788 - Injection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.) 50 MCG (250 IU) 24.559 - - - - - -
J2790 - Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) 300 MCG (1500 IU) 83.362 - - - - - -
J2791 - Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu 100 IU 4.894 - - - - - -
J2792 - Injection, rho d immune globulin, intravenous, human, solvent detergent, 100 iu 100 IU 32.863 - - - - - -
J2794 - Injection, risperidone (risperdal consta), 0.5 mg 0.5 MG 10.99 - - - - - -
J2795 - Injection, ropivacaine hydrochloride, 1 mg 1 MG 0.073 - - - - - -
J2798 - Injection, risperidone, (perseris), 0.5 mg 0.5 mg 12.189 - - - - - -
J2799 - Injection, risperidone (uzedy), 1 mg 1 MG 24.719 - - - - - -
* 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