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 21 * 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
J7354 - Cantharidin for topical administration, 0.7%, single unit dose applicator (3.2 mg) Per 3.2 mg single-use applicator 711.753 - - - - - -
J7402 - Mometasone furoate sinus implant, (sinuva), 10 micrograms 10 MCG 11.345 - - - - - -
J7500 - Azathioprine, oral, 50 mg 50 MG 1.194 - - - - - -
J7502 - Cyclosporine, oral, 100 mg 100 MG 2.199 - - - - - -
J7503 - Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg 0.25 MG 1.803 - - - - - -
J7504 - Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg 250 MG 4355.733 - - - - - -
J7507 - Tacrolimus, immediate release, oral, 1 mg 1 MG 0.176 - - - - - -
J7508 - Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg 0.1 MG 0.568 - - - - - -
J7509 - Methylprednisolone oral, per 4 mg 4 MG 0.247 - - - - - -
J7510 - Prednisolone oral, per 5 mg 5 MG 0.572 - - - - - -
J7511 - Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg 25 MG 950.264 - - - - - -
J7512 - Prednisone, immediate release or delayed release, oral, 1 mg 1 MG 0.005 - - - - - -
J7515 - Cyclosporine, oral, 25 mg 25 MG 0.826 - - - - - -
J7516 - Injection, cyclosporine, 250 mg 250 MG 71.36 - - - - - -
J7517 - Mycophenolate mofetil, oral, 250 mg 250 MG 0.152 - - - - - -
J7518 - Mycophenolic acid, oral, 180 mg 180 MG 0.478 - - - - - -
J7519 - Injection, mycophenolate mofetil, 10 mg 10 MG 0.412 - - - - - -
J7520 - Sirolimus, oral, 1 mg 1 MG 1.063 - - - - - -
J7525 - Tacrolimus, parenteral, 5 mg 5 MG 254.666 - - - - - -
J7527 - Everolimus, oral, 0.25 mg 0.25 MG 2.322 - - - - - -
J7605 - Arformoterol, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 15 micrograms 15 mcg 0.809 - - - - - -
J7606 - Formoterol fumarate, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 20 micrograms 20 MCG 1.888 - - - - - -
J7608 - Acetylcysteine, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per gram 1 GM 8.147 - - - - - -
J7611 - Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 1 mg 1 MG 0.16 - - - - - -
J7612 - Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 0.5 mg 0.5 MG 0.294 - - - - - -
* 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