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 23 * 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
J9023 - Injection, avelumab, 10 mg 10 MG 96.948 - - - - - -
J9025 - Injection, azacitidine, 1 mg 1 MG 0.285 - - - - - -
J9027 - Injection, clofarabine, 1 mg 1 MG 8.455 - - - - - -
J9028 - Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram 1 MCG 94.87 - - - - - -
J9029 - Intravesical instillation, nadofaragene firadenovec-vncg, per therapeutic dose PER THERAPEUTIC DOSE 63402.043 - - - - - -
J9030 - Bcg live intravesical instillation, 1 mg 1 MG 2.999 - - - - - -
J9032 - Injection, belinostat, 10 mg 10 MG 50.28 - - - - - -
J9033 - Injection, bendamustine hydrochloride, 1 mg 1 MG 1.802 - - - - - -
J9034 - Injection, bendamustine hcl (bendeka), 1 mg 1 MG 13.453 - - - - - -
J9035 - Injection, bevacizumab, 10 mg 10 MG 73.19 - - - - - -
J9036 - Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mg 1 MG 17.125 - - - - - -
J9039 - Injection, blinatumomab, 1 microgram 1 MCG 152.507 - - - - - -
J9040 - Injection, bleomycin sulfate, 15 units 15 UNITS 20.911 - - - - - -
J9041 - Injection, bortezomib, 0.1 mg 0.1 MG 2.22 - - - - - -
J9042 - Injection, brentuximab vedotin, 1 mg 1 MG 248.93 - - - - - -
J9043 - Injection, cabazitaxel, 1 mg 1 MG 224.09 - - - - - -
J9045 - Injection, carboplatin, 50 mg 50 MG 3.63 - - - - - -
J9047 - Injection, carfilzomib, 1 mg 1 MG 51.965 - - - - - -
J9049 - Injection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg 0.1 MG 1.443 - - - - - -
J9050 - Injection, carmustine, 100 mg 100 MG 255.32 - - - - - -
J9055 - Injection, cetuximab, 10 mg 10 MG 77.095 - - - - - -
J9056 - Injection, bendamustine hydrochloride (vivimusta), 1 mg 1 MG 28.652 - - - - - -
J9060 - Injection, cisplatin, powder or solution, 10 mg 10 MG 2.687 - - - - - -
J9061 - Injection, amivantamab-vmjw, 2 mg 2 MG 21.558 - - - - - -
J9063 - Injection, mirvetuximab soravtansine-gynx, 1 mg 1 MG 68.109 - - - - - -
* 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