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 3 * 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
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.507 - - - - - -
J0349 - Injection, rezafungin, 1 mg 1 MG 10.424 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 4.077 - - - - - -
J0401 - Injection, aripiprazole (abilify maintena), 1 mg 1 MG 7.07 - - - - - -
J0402 - Injection, aripiprazole (abilify asimtufii), 1 mg 1 MG 5.917 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 2.128 - - - - - -
J0457 - Injection, aztreonam, 100 mg 100 MG 2.071 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.107 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 173.837 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 40.728 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 4657.581 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.933 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 54.908 - - - - - -
J0491 - Injection, anifrolumab-fnia, 1 mg 1 MG 17.763 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 14.904 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 16.888 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 165.894 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 17.368 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 26.821 - - - - - -
J0565 - Injection, bezlotoxumab, 10 mg 10 MG 39.865 - - - - - -
J0577 - Injection, buprenorphine extended-release (brixadi), less than or equal to 7 days of therapy Less than or equal to 7 days of therapy 428.656 - - - - - -
J0578 - Injection, buprenorphine extended release (brixadi), greater than 7 days and up to 28 days of therapy Greater than 7 days and up to 28 days of therapy 1714.625 - - - - - -
J0583 - Injection, bivalirudin, 1 mg 1 MG 0.163 - - - - - -
J0584 - Injection, burosumab-twza 1 mg 1 MG 469.726 - - - - - -
J0585 - Injection, onabotulinumtoxina, 1 unit 1 UNIT 6.471 - - - - - -
* 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