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 28 * 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
J9353 - Injection, margetuximab-cmkb, 5 mg 5 MG 49.4 - - - - - -
J9354 - Injection, ado-trastuzumab emtansine, 1 mg 1 MG 40.968 - - - - - -
J9355 - Injection, trastuzumab, excludes biosimilar, 10 mg 10 MG 77.051 - - - - - -
J9356 - Injection, trastuzumab, 10 mg and hyaluronidase-oysk 10 MG 63.064 - - - - - -
J9357 - Injection, valrubicin, intravesical, 200 mg 200 MG 1392.518 - - - - - -
J9358 - Injection, fam-trastuzumab deruxtecan-nxki, 1 mg 1 MG 28.81 - - - - - -
J9359 - Injection, loncastuximab tesirine-lpyl, 0.075 mg 0.075 MG 212.118 - - - - - -
J9360 - Injection, vinblastine sulfate, 1 mg 1 MG 4.834 - - - - - -
J9370 - Vincristine sulfate, 1 mg 1 MG 8.332 - - - - - -
J9380 - Injection, teclistamab-cqyv, 0.5 mg 0.5 MG 32.551 - - - - - -
J9381 - Injection, teplizumab-mzwv, 5 mcg 5 MCG 37.236 - - - - - -
J9390 - Injection, vinorelbine tartrate, 10 mg 10 MG 6.503 - - - - - -
J9394 - Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg 25 MG 12.257 - - - - - -
J9395 - Injection, fulvestrant, 25 mg 25 MG 6.656 - - - - - -
J9400 - Injection, ziv-aflibercept, 1 mg 1 MG 7.984 - - - - - -
P9041 - Infusion, albumin (human), 5%, 50 ml 50 ML 10.6153 - - - - 95% 10.6153
P9045 - Infusion, albumin (human), 5%, 250 ml 250 ML 53.077 - - - - 95% 53.077
P9046 - Infusion, albumin (human), 25%, 20 ml 20 ML 21.231 - - - - 95% 21.231
P9047 - Infusion, albumin (human), 25%, 50 ml 50 ML 53.077 - - - - 95% 53.077
Q0138 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) 1 MG 0.377 - - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.377 - - - - - -
Q0162 - Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 1 MG 0.013 - - - - - -
Q0167 - Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 2.5 MG 1.849 - - - - - -
Q0224 - Injection, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, and who either have moderate-to-severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments, and are unlikely to mount an adequate immune response to covid-19 vaccination, 4500 mg 4500 MG 6583.5 95% 6583.5 - - - -
Q0249 - Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, 1 mg 1 MG 7.569 95% 7.569 - - - -
* 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