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 8 * 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
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.773 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.379 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 563.098 - - - - - -
J1300 - Injection, eculizumab, 10 mg 10 MG 224.159 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 21.682 - - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 18.127 - - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 220.588 - - - - - -
J1304 - Injection, tofersen, 1 mg 1 MG 155.338 - - - - - -
J1305 - Injection, evinacumab-dgnb, 5mg 5 MG 186.306 - - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.277 - - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 293.924 - - - - - -
J1323 - Injection, elranatamab-bcmm, 1 mg 1 MG 177.647 - - - - - -
J1325 - Injection, epoprostenol, 0.5 mg 0.5 MG 16.436 - - - - - -
J1335 - Injection, ertapenem sodium, 500 mg 500 MG 11.014 - - - - - -
J1364 - Injection, erythromycin lactobionate, per 500 mg 500 MG 62.14 - - - - - -
J1380 - Injection, estradiol valerate, up to 10 mg 10 MG 7.942 - - - - - -
J1410 - Injection, estrogen conjugated, per 25 mg 25 MG 382.912 - - - - - -
J1430 - Injection, ethanolamine oleate, 100 mg 100 MG 491.653 - - - - - -
J1437 - Injection, ferric derisomaltose, 10 mg 10 MG 20.774 - - - - - -
J1439 - Injection, ferric carboxymaltose, 1 mg 1 MG 1.105 - - - - - -
J1440 - Fecal microbiota, live - jslm, 1 ml 1 ML 63.6 - - - - - -
J1442 - Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram 1 MCG 0.984 - - - - - -
J1447 - Injection, tbo-filgrastim, 1 microgram 1 MCG 0.404 - - - - - -
J1448 - Injection, trilaciclib, 1mg 1 MG 5.366 - - - - - -
J1449 - Injection, eflapegrastim-xnst, 0.1 mg 0.1 MG 22.135 - - - - - -
* 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