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 5 * 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
J0641 - Injection, levoleucovorin, not otherwise specified, 0.5 mg 0.5 MG 0.058 - - - - - -
J0642 - Injection, levoleucovorin (khapzory), 0.5 mg 0.5 MG 1.421 - - - - - -
J0650 - Injection, levothyroxine sodium, not otherwise specified, 10 mcg 10 MCG 6.872 - - - - - -
J0651 - Injection, levothyroxine sodium (fresenius kabi), not therapeutically equivalent to j0650, 10 mcg 10 MCG 6.829 - - - - - -
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 1.47 - - - - - -
J0670 - Injection, mepivacaine hydrochloride, per 10 ml 10 ML 3.954 - - - - - -
J0687 - Injection, cefazolin sodium (wg critical care), not therapeutically equivalent to j0690, 500 mg 500 MG 0.948 - - - - - -
J0688 - Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg 500 MG 0.926 - - - - - -
J0689 - Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg 500 MG 1.3 - - - - - -
J0690 - Injection, cefazolin sodium, 500 mg 500 MG 0.798 - - - - - -
J0692 - Injection, cefepime hydrochloride, 500 mg 500 MG 1.222 - - - - - -
J0694 - Injection, cefoxitin sodium, 1 gm 1 GM 4.783 - - - - - -
J0695 - Injection, ceftolozane 50 mg and tazobactam 25 mg 75mg (50mg cft/25mg taz) 9.066 - - - - - -
J0696 - Injection, ceftriaxone sodium, per 250 mg 250 MG 0.43 - - - - - -
J0697 - Injection, sterile cefuroxime sodium, per 750 mg 750 MG 1.847 - - - - - -
J0699 - Injection, cefiderocol, 10 mg 10 mg 2.419 - - - - - -
J0701 - Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg 500 MG 6.045 - - - - - -
J0702 - Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3 MG & 3 MG 6.956 - - - - - -
J0703 - Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg 500 MG 4.958 - - - - - -
J0712 - Injection, ceftaroline fosamil, 10 mg 10 MG 4.228 - - - - - -
J0713 - Injection, ceftazidime, per 500 mg 500 MG 1.571 - - - - - -
J0714 - Injection, ceftazidime and avibactam, 0.5 g/0.125 g .625 GM 104.73 - - - - - -
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 3.913 - - - - - -
* 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