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 7 * 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
J0894 - Injection, decitabine, 1 mg 1 MG 2.334 - - - - - -
J0895 - Injection, deferoxamine mesylate, 500 mg 500 MG 8.937 - - - - - -
J0896 - Injection, luspatercept-aamt, 0.25 mg 0.25 MG 41.275 - - - - - -
J0897 - Injection, denosumab, 1 mg 1 MG 27.656 - - - - - -
J1000 - Injection, depo-estradiol cypionate, up to 5 mg 5 MG 38.653 - - - - - -
J1010 - Injection, methylprednisolone acetate, 1 mg 1 MG 0.117 - - - - - -
J1071 - Injection, testosterone cypionate, 1 mg 1 MG 0.032 - - - - - -
J1096 - Dexamethasone, lacrimal ophthalmic insert, 0.1 mg 0.1 MG 112.947 - - - - - -
J1100 - Injection, dexamethasone sodium phosphate, 1 mg 1 MG 0.108 - - - - - -
J1110 - Injection, dihydroergotamine mesylate, per 1 mg 1 MG 41.037 - - - - - -
J1120 - Injection, acetazolamide sodium, up to 500 mg 500 MG 21.618 - - - - - -
J1160 - Injection, digoxin, up to 0.5 mg 0.5 MG 8.819 - - - - - -
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 5069.98 - - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.471 - - - - - -
J1171 - Injection, hydromorphone, 0.1 mg 0.1 MG 0.089 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 80.875 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.734 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 15.73 - - - - - -
J1203 - Injection, cipaglucosidase alfa-atga, 5 mg 5 MG 89.377 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 60.464 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 715.39 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 20.661 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.672 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.867 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 7.39 - - - - - -
* 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