ASP Drug Pricing - (2nd Quarter)
April 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2024 (4th Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 1 * Effective April 1, 2025 through June 30, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
A9573 - Injection, gadopiclenol, 1 ml 1 ML 3.472 - - - - - -
A9575 - Injection, gadoterate meglumine, 0.1 ml 0.1 ML 0.119 - - - - - -
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.434 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.815 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.808 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.491 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.712 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.264 - - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1378.413 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 3.866 - - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.206 - - - - - -
J0129 - Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 10 MG 43.377 - - - - - -
J0131 - Injection, acetaminophen, not otherwise specified,10 mg 10 MG 0.052 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 0.446 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.035 - - - - - -
J0134 - Injection, acetaminophen (fresenius kabi), not therapeutically equivalent to j0131, 10 mg 10 MG 0.052 - - - - - -
J0136 - Injection, acetaminophen (b braun), not therapeutically equivalent to j0131, 10 mg 10 MG 0.049 - - - - - -
J0137 - Injection, acetaminophen (hikma), not therapeutically equivalent to j0131, 10 mg 10 MG 0.025 - - - - - -
J0138 - Injection, acetaminophen 10 mg and ibuprofen 3 mg 10 MG/3MG 0.218 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.386 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.732 - - - - - -
J0172 - Injection, aducanumab-avwa, 2 mg 2 MG 5.978 - - - - - -
J0173 - Injection, epinephrine (belcher), not therapeutically equivalent to j0171, 0.1 mg 0.1 MG 2.252 - - - - - -
J0174 - Lecanemab-irmb, for intravenous injection, 1 mg 1 MG 1.33 - - - - - -
* Effective April 1, 2025 through June 30, 2025

Drugs not otherwise classified - April 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2025 through June 30, 2025

Drug name Dosage Payment limit Notes
Diltiazem Hydrochloride 5 MG 0.416
Metoprolol Tartrate 1 MG 0.123
Vasopressin (Long Grove) 1 UNIT 3.272 Added April 2025

ASP (Average Sale Price) Drug Pricing History