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 6 * 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
J0737 - Injection, clindamycin phosphate (baxter), not therapeutically equivalent to j0736, 300 mg 300 MG 2.527 - - - - - -
J0739 - Injection, cabotegravir, 1mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv) 1 mg 6.887 - - - - - -
J0740 - Injection, cidofovir, 375 mg 375 MG 521.827 - - - - - -
J0741 - Injection, cabotegravir and rilpivirine, 2mg/3mg 2MG/3MG 23.132 - - - - - -
J0742 - Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg 4 MG-4 MG-2 MG 2.497 - - - - - -
J0743 - Injection, cilastatin sodium; imipenem, per 250 mg 250 MG 7.337 - - - - - -
J0744 - Injection, ciprofloxacin for intravenous infusion, 200 mg 200 MG 2.098 - - - - - -
J0750 - Emtricitabine 200mg and tenofovir disoproxil fumarate 300mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv) 200 mg/300 mg 1.277 - - - - - -
J0751 - Emtricitabine 200mg and tenofovir alafenamide 25mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv) 200 mg/25 mg 71.272 - - - - - -
J0770 - Injection, colistimethate sodium, up to 150 mg 150 MG 11.942 - - - - - -
J0775 - Injection, collagenase, clostridium histolyticum, 0.01 mg 0.01 MG 73.375 - - - - - -
J0780 - Injection, prochlorperazine, up to 10 mg 10 MG 2.917 - - - - - -
J0791 - Injection, crizanlizumab-tmca, 5 mg 5 MG 129.502 - - - - - -
J0801 - Injection, corticotropin (acthar gel), up to 40 units 40 UNITS 3893.429 - - - - - -
J0802 - Injection, corticotropin (ani), up to 40 units up to 40 Units 3445.584 - - - - - -
J0834 - Injection, cosyntropin, 0.25 mg 0.25 MG 33.397 - - - - - -
J0840 - Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram UP TO 1 GM 1755.811 - - - - - -
J0841 - Injection, crotalidae immune f(ab')2 (equine), 120 mg 120 MG 1043.547 - - - - - -
J0850 - Injection, cytomegalovirus immune globulin intravenous (human), per vial PER VIAL 1812.007 - - - - - -
J0870 - Injection, imetelstat, 1 mg 1 MG 55.51 - - - - - -
J0872 - Injection, daptomycin (xellia), unrefrigerated, not therapeutically equivalent to j0878 or j0873, 1 mg 1 MG 0.051 - - - - - -
J0873 - Injection, daptomycin (xellia), not therapeutically equivalent to j0878 or j0872, 1 mg 1 MG 0.034 - - - - - -
J0874 - Injection, daptomycin (baxter), not therapeutically equivalent to j0878, 1 mg 1 MG 0.065 - - - - - -
J0875 - Injection, dalbavancin, 5 mg 5 MG 15.567 - - - - - -
J0877 - Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg 1 MG 0.055 - - - - - -
* 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