ASP Drug Pricing - (4th Quarter)
October 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2025 (2nd 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 October 1, 2025 - December 31, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.476 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.73 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.275 - - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1426.241 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 4.02 - - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.302 - - - - - -
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 44.109 - - - - - -
J0131 - Injection, acetaminophen, not otherwise specified,10 mg 10 MG 0.057 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 0.385 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.037 - - - - - -
J0134 - Injection, acetaminophen (fresenius kabi), not therapeutically equivalent to j0131, 10 mg 10 MG 0.055 - - - - - -
J0136 - Injection, acetaminophen (b braun), not therapeutically equivalent to j0131, 10 mg 10 MG 0.048 - - - - - -
J0137 - Injection, acetaminophen (hikma), not therapeutically equivalent to j0131, 10 mg 10 MG 0.049 - - - - - -
J0138 - Injection, acetaminophen 10 mg and ibuprofen 3 mg 10 MG/3MG 0.041 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.555 - - - - - -
J0163 - Injection, epinephrine in sodium chloride (endo), 0.1 mg 0.1 MG 0.974 - - - - - -
J0165 - Injection, epinephrine, not otherwise specified, 0.1 mg 0.1 MG 0.48 - - - - - -
J0166 - Injection, epinephrine (bpi), not therapeutically equivalent to j0165, 0.1 mg 0.1 MG 1.058 - - - - - -
J0167 - Injection, epinephrine (hospira), not therapeutically equivalent to j0165, 0.1 mg 0.1 MG 1.422 - - - - - -
J0168 - Injection, epinephrine (international medication systems), not therapeutically equivalent to j0165, 0.1 mg 0.1 MG 2.544 - - - - - -
J0169 - Injection, epinephrine (adrenalin), not therapeutically equivalent to j0165, 0.1 mg 0.1 MG 1.359 - - - - - -
J0172 - Injection, aducanumab-avwa, 2 mg 2 MG 5.978 - - - - - -
J0174 - Lecanemab-irmb, for intravenous injection, 1 mg 1 MG 1.324 - - - - - -
J0175 - Injection, donanemab-azbt, 2 mg 2 MG 4.133 - - - - - -
* Effective October 1, 2025 - December 31, 2025

Drugs not otherwise classified - October 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2025 - December 31, 2025

Drug name Dosage Payment limit Notes
Vasopressin (Long Grove) 1 UNIT 2.462

ASP (Average Sale Price) Drug Pricing History