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 9 * 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
J1450 - Injection fluconazole, 200 mg 200 MG 2.385 - - - - - -
J1453 - Injection, fosaprepitant, 1 mg 1 MG 0.12 - - - - - -
J1454 - Injection, fosnetupitant 235 mg and palonosetron 0.25 mg 0.25 MG 658.1 - - - - - -
J1455 - Injection, foscarnet sodium, per 1000 mg 1000 MG 38.277 - - - - - -
J1456 - Injection, fosaprepitant (teva), not therapeutically equivalent to j1453, 1 mg 1 MG 0.441 - - - - - -
J1458 - Injection, galsulfase, 1 mg 1 MG 484.922 - - - - - -
J1459 - Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 49.284 - - - - - -
J1460 - Injection, gamma globulin, intramuscular, 1 cc 1 CC 49.416 - - - - - -
J1551 - Injection, immune globulin (cutaquig), 100 mg 100 MG 14.512 - - - - - -
J1552 - Injection, immune globulin (alyglo), 500 mg 500 MG 146.889 - - - - - -
J1554 - Injection, immune globulin (asceniv), 500 mg 500 MG 494.97 - - - - - -
J1555 - Injection, immune globulin (cuvitru), 100 mg 100 MG 16.611 - - - - - -
J1556 - Injection, immune globulin (bivigam), 500 mg 500 MG 76.632 - - - - - -
J1557 - Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 56.766 - - - - - -
J1558 - Injection, immune globulin (xembify), 100 mg 100 MG 14.255 - - - - - -
J1559 - Injection, immune globulin (hizentra), 100 mg 100 MG 13.637 - - - - - -
J1560 - Injection, gamma globulin, intramuscular, over 10 cc 10 CC 494.164 - - - - - -
J1561 - Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg 500 MG 49.009 - - - - - -
J1566 - Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg 500 MG 81.431 - - - - - -
J1568 - Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 49.301 - - - - - -
J1569 - Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg 500 MG 46.459 - - - - - -
J1570 - Injection, ganciclovir sodium, 500 mg 500 MG 28.743 - - - - - -
J1571 - Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml 0.5 ML 65.935 - - - - - -
J1573 - Injection, hepatitis b immune globulin (hepagam b), intravenous, 0.5 ml 0.5 ML 65.935 - - - - - -
J1575 - Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin 100 MG 17.687 - - - - - -
* 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