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 5 * 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
J0651 - Injection, levothyroxine sodium (fresenius kabi), not therapeutically equivalent to j0650, 10 mcg 10 MCG 6.398 - - - - - -
J0652 - Injection, levothyroxine sodium (hikma), not therapeutically equivalent to j0650, 10 mcg 10 MCG 5.136 - - - - - -
J0665 - Injection, bupivicaine, not otherwise specified, 0.5 mg 0.5 MG 0.01 - - - - - -
J0666 - Injection, bupivacaine liposome, 1 mg 1 MG 1.421 - - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.627 - - - - - -
J0687 - Injection, cefazolin sodium (wg critical care), not therapeutically equivalent to j0690, 500 mg 500 MG 0.973 - - - - - -
J0688 - Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg 500 MG 0.982 - - - - - -
J0689 - Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg 500 MG 1.245 - - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.828 - - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.201 - - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 5.01 - - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 8.041 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.493 - - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 2.013 - - - - - -
J0699 - Injection, cefiderocol, 10 mg 10 mg 2.282 - - - - - -
J0701 - Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.804 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.848 - - - - - -
J0703 - Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg 500 MG 5.044 - - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 3.991 - - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 1.6 - - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 100.496 - - - - - -
J0717 - Injection, certolizumab pegol, 1 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) 1 MG 3.984 - - - - - -
J0725 - Injection, chorionic gonadotropin, per 1,000 usp units 1000 UNITS 18.252 - - - - - -
J0735 - Injection, clonidine hydrochloride, 1 mg 1 MG 16.202 - - - - - -
J0736 - Injection, clindamycin phosphate, 300 mg 300 MG 1.613 - - - - - -
* 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