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 4 * 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
J0586 - Injection, abobotulinumtoxina, 5 units 5 Unit 8.526 - - - - - -
J0587 - Injection, rimabotulinumtoxinb, 100 units 100 UNITS 12.991 - - - - - -
J0588 - Injection, incobotulinumtoxin a, 1 unit 1 UNIT 5.305 - - - - - -
J0592 - Injection, buprenorphine hydrochloride, 0.1 mg 0.1 MG 4.303 - - - - - -
J0594 - injection, busulfan, 1 mg 1 MG 1.416 - - - - - -
J0595 - Injection, butorphanol tartrate, 1 mg 1 MG 5.68 - - - - - -
J0596 - Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units 10 UNITS 34.665 - - - - - -
J0597 - Injection, c-1 esterase inhibitor (human), berinert, 10 units 10 UNITS 72.456 - - - - - -
J0598 - Injection, c-1 esterase inhibitor (human), cinryze, 10 units 10 UNITS 64.066 - - - - - -
J0600 - Injection, edetate calcium disodium, up to 1000 mg 1000 MG 6084.101 - - - - - -
J0612 - Injection, calcium gluconate, not otherwise specified, 10 mg 10 MG 0.036 - - - - - -
J0613 - Injection, calcium gluconate (wg critical care), not therapeutically equivalent to j0612, 10 mg 10 MG 0.106 - - - - - -
J0630 - Injection, calcitonin salmon, up to 400 units 400 UNITS 1142.411 - - - - - -
J0637 - Injection, caspofungin acetate, 5 mg 5 MG 5.055 - - - - - -
J0638 - Injection, canakinumab, 1 mg 1 MG 135.878 - - - - - -
J0640 - Injection, leucovorin calcium, per 50 mg 50 MG 4.162 - - - - - -
J0641 - Injection, levoleucovorin, not otherwise specified, 0.5 mg 0.5 MG 0.042 - - - - - -
J0642 - Injection, levoleucovorin (khapzory), 0.5 mg 0.5 MG 1.35 - - - - - -
J0650 - Injection, levothyroxine sodium, not otherwise specified, 10 mcg 10 MCG 5.39 - - - - - -
J0651 - Injection, levothyroxine sodium (fresenius kabi), not therapeutically equivalent to j0650, 10 mcg 10 MCG 3.818 - - - - - -
J0652 - Injection, levothyroxine sodium (hikma), not therapeutically equivalent to j0650, 10 mcg 10 MCG 5.136 - - - - - -
J0665 - Injection, bupivicaine, not otherwise specified, 0.5 mg 0.5 MG 0.01 - - - - - -
J0666 - Injection, bupivacaine liposome, 1 mg 1 MG 1.445 - - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.554 - - - - - -
J0687 - Injection, cefazolin sodium (wg critical care), not therapeutically equivalent to j0690, 500 mg 500 MG 1.109 - - - - - -
* 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