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 6 * 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
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 0.828 - - - - - -
J0750 - Emtricitabine 200mg and tenofovir disoproxil fumarate 300mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv) 200 mg/300 mg 1.817 - - - - - -
J0751 - Emtricitabine 200mg and tenofovir alafenamide 25mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv) 200 mg/25 mg 71.289 - - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 12.161 - - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 70.887 - - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 2.953 - - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 128.68 - - - - - -
J0801 - Injection, corticotropin (acthar gel), up to 40 units 40 UNITS 3827.827 - - - - - -
J0802 - Injection, corticotropin (ani), up to 40 units up to 40 Units 3468.848 - - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 33.433 - - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 1779.644 - - - - - -
J0841 - Injection, crotalidae immune f(ab')2 (equine), 120 mg 120 MG 1027.168 - - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1814.108 - - - - - -
J0872 - Injection, daptomycin (xellia), unrefrigerated, not therapeutically equivalent to j0878 or j0873, 1 mg 1 MG 0.042 - - - - - -
J0873 - Injection, daptomycin (xellia), not therapeutically equivalent to j0878 or j0872, 1 mg 1 MG 0.037 - - - - - -
J0874 - Injection, daptomycin (baxter), not therapeutically equivalent to j0878, 1 mg 1 MG 0.067 - - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 15.6 - - - - - -
J0877 - Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg 1 MG 0.042 - - - - - -
J0878 - Injection, daptomycin, 1 mg 1 MG 0.035 - - - - - -
J0881 - Injection, darbepoetin alfa, 1 microgram (non-esrd use) 1 MCG 2.972 - - - - - -
J0882 - Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) 1 MCG 2.972 - - - - - -
J0884 - Injection, argatroban, 1 mg (for esrd on dialysis) 1 MG 0.803 - - - - - -
J0885 - Injection, epoetin alfa, (for non-esrd use), 1000 units 1000 UNITS 6.461 - - - - - -
J0887 - Injection, epoetin beta, 1 microgram, (for esrd on dialysis) 1 MCG 1.224 - - - - - -
J0888 - Injection, epoetin beta, 1 microgram, (for non esrd use) 1 MCG 1.206 - - - - - -
* 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