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 2 * 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
J0179 - Injection, brolucizumab-dbll, 1 mg 1 MG 338.891 - - - - - -
J0180 - Injection, agalsidase beta, 1 mg 1 MG 223.517 - - - - - -
J0185 - Injection, aprepitant, 1 mg 1 MG 1.701 - - - - - -
J0202 - Injection, alemtuzumab, 1 mg 1 MG 2413.358 - - - - - -
J0206 - Injection, allopurinol sodium, 1 mg 1 MG 4.395 - - - - - -
J0217 - Injection, velmanase alfa-tycv, 1 mg 1 MG 440.808 - - - - - -
J0218 - Injection, olipudase alfa-rpcp, 1 mg 1 MG 381.579 - - - - - -
J0219 - Injection, avalglucosidase alfa-ngpt, 4 mg 4 MG 77.861 - - - - - -
J0221 - Injection, alglucosidase alfa, (lumizyme), 10 mg 10 MG 201.64 - - - - - -
J0222 - Injection, patisiran, 0.1 mg 0.1 MG 98.833 - - - - - -
J0223 - Injection, givosiran, 0.5 mg 0.5 MG 115.466 - - - - - -
J0224 - Injection, lumasiran, 0.5 mg 0.5 MG 318.006 - - - - - -
J0225 - Injection, vutrisiran, 1 mg 1 MG 4917.749 - - - - - -
J0248 - Injection, remdesivir, 1 mg 1 MG 6.354 - - - - - -
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 5.091 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 5.512 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 0.54 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 5.17 - - - - - -
J0282 - Injection, amiodarone hydrochloride, 30 mg 30 MG 0.394 - - - - - -
J0283 - Injection, amiodarone hydrochloride (nexterone), 30 mg 30 MG 2.524 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 50.066 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 23.975 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.714 - - - - - -
J0291 - Injection, plazomicin, 5 mg 5 MG 3.574 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 1.641 - - - - - -
* 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