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 16 * 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
J2800 - Injection, methocarbamol, up to 10 ml 10 ML 6.566 - - - - - -
J2802 - Injection, romiplostim, 1 microgram 1 MCG 10.543 - - - - - -
J2805 - Injection, sincalide, 5 micrograms 5 MCG 114.387 - - - - - -
J2820 - Injection, sargramostim (gm-csf), 50 mcg 50 MCG 60.018 - - - - - -
J2860 - Injection, siltuximab, 10 mg 10 MG 155.968 - - - - - -
J2916 - Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg 12.5 MG 1.991 - - - - - -
J2919 - Injection, methylprednisolone sodium succinate, 5 mg 5 MG 0.268 - - - - - -
J2997 - Injection, alteplase recombinant, 1 mg 1 MG 91.481 - - - - - -
J3000 - Injection, streptomycin, up to 1 gm 1 GM 28.263 - - - - - -
J3010 - Injection, fentanyl citrate, 0.1 mg 0.1 MG 0.852 - - - - - -
J3032 - Injection, eptinezumab-jjmr, 1 mg 1 MG 19.323 - - - - - -
J3055 - Injection, talquetamab-tgvs, 0.25 mg 0.25 MG 69.972 - - - - - -
J3060 - Injection, taliglucerase alfa, 10 units 10 UNITS 41.621 - - - - - -
J3090 - Injection, tedizolid phosphate, 1 mg 1 MG 1.808 - - - - - -
J3095 - Injection, telavancin, 10 mg 10 MG 7.396 - - - - - -
J3101 - Injection, tenecteplase, 1 mg 1 MG 162.431 - - - - - -
J3105 - Injection, terbutaline sulfate, up to 1 mg 1 MG 2.143 - - - - - -
J3111 - Injection, romosozumab-aqqg, 1 mg 1 MG 11.486 - - - - - -
J3121 - Injection, testosterone enanthate, 1 mg 1 MG 0.053 - - - - - -
J3145 - Injection, testosterone undecanoate, 1 mg 1 MG 1.918 - - - - - -
J3230 - Injection, chlorpromazine hcl, up to 50 mg 50 MG 30.479 - - - - - -
J3240 - Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial 0.9 MG 2067.908 - - - - - -
J3241 - Injection, teprotumumab-trbw, 10 mg 10 MG 347.102 - - - - - -
J3243 - Injection, tigecycline, 1 mg 1 MG 0.63 - - - - - -
J3245 - Injection, tildrakizumab, 1 mg 1 MG 133.178 - - - - - -
* 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