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 19 * 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
J7182 - Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu 1 IU 1.427 - - - - - - 1
J7183 - Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco 1 I.U. VWF:RCO 1.283 - - - - - - 1
J7185 - Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. 1 IU 1.499 - - - - - - 1
J7186 - Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. PER FACTOR VIII IU 1.199 - - - - - - 1
J7187 - Injection, von willebrand factor complex (humate-p), per iu vwf:rco 1 IU 1.446 - - - - - - 1
J7188 - Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. 1 IU 3.229 - - - - - - 1
J7189 - Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram 1 MCG 2.549 - - - - - - 1
J7190 - Factor viii (antihemophilic factor, human) per i.u. 1 IU 1.117 - - - - - - 1
J7192 - Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified 1 IU 1.542 - - - - - - 1
J7193 - Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. 1 IU 1.341 - - - - - - 1
J7194 - Factor ix, complex, per i.u. 1 IU 1.655 - - - - - - 1
J7195 - Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified 1 IU 1.84 - - - - - - 1
J7197 - Antithrombin iii (human), per i.u. 1 IU 3.961 - - - - - -
J7198 - Anti-inhibitor, per i.u. 1 IU 2.363 - - - - - - 1
J7200 - Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu 1 IU 1.651 - - - - - - 1
J7201 - Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. 1 IU 3.575 - - - - - - 1
J7202 - Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. 1 IU 5.207 - - - - - - 1
J7203 - Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu 1 IU 4.394 - - - - - - 1
J7204 - Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu 1 IU 2.185 - - - - - - 1
J7205 - Injection, factor viii fc fusion protein (recombinant), per iu 1 IU 2.338 - - - - - - 1
J7207 - Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. 1 IU 2.099 - - - - - - 1
J7208 - Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. 1 IU 2.446 - - - - - - 1
J7209 - Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. 1 IU 1.239 - - - - - - 1
J7210 - Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u. 1 IU 1.516 - - - - - - 1
J7211 - Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u. 1 IU 1.484 - - - - - - 1
* 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