• Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2024 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
Page 1 * Effective January 1, 2025 through March 31, 2025
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
A9576 - Injection, gadoteridol, (prohance multipack), per ml 1 ML 1.46 - - - - - -
A9577 - Injection, gadobenate dimeglumine (multihance), per ml 1 ML 1.824 - - - - - -
A9578 - Injection, gadobenate dimeglumine (multihance multipack), per ml 1 ML 1.793 - - - - - -
A9579 - Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1 ML 1.484 - - - - - -
A9581 - Injection, gadoxetate disodium, 1 ml 1 ML 14.701 - - - - - -
A9585 - Injection, gadobutrol, 0.1 ml 0.1 ML 0.278 - - - - - -
A9589 - Instillation, hexaminolevulinate hydrochloride, 100 mg 100 MG 1378.71 - - - - - -
A9606 - Radium ra-223 dichloride, therapeutic, per microcurie 1 microCurie N/A - - - - - -
J0121 - Injection, omadacycline, 1 mg 1 MG 3.916 - - - - - -
J0122 - Injection, eravacycline, 1 mg 1 MG 1.21 - - - - - -
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 43.797 - - - - - -
J0131 - Injection, acetaminophen, not otherwise specified,10 mg 10 MG 0.048 - - - - - -
J0132 - Injection, acetylcysteine, 100 mg 100 MG 0.545 - - - - - -
J0133 - Injection, acyclovir, 5 mg 5 MG 0.051 - - - - - -
J0134 - Injection, acetaminophen (fresenius kabi), not therapeutically equivalent to j0131, 10 mg 10 MG 0.042 - - - - - -
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 0.048 - - - - - -
J0153 - Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1 MG 0.316 - - - - - -
J0171 - Injection, adrenalin, epinephrine, 0.1 mg 0.1 MG 0.762 - - - - - -
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 2.384 - - - - - -
J0174 - Injection, lecanemab-irmb, 1 mg 1 MG 1.33 - - - - - -
J0175 - Injection, donanemab-azbt, 2 mg 2 MG 4.094 - - - - - -
J0177 - Injection, aflibercept hd, 1 mg 1 MG 329.056 - - - - - -
J0178 - Injection, aflibercept, 1 mg 1 MG 801.065 - - - - - -
* Effective January 1, 2025 through March 31, 2025

Drugs not otherwise classified - January 2025

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2025 through March 31, 2025

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.33
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.783
Diltiazem Hydrochloride 5 MG 0.355
Doxycycline Hyclate 100 MG 12.599
Famotidine 10 MG 0.289
Flumazenil 0.1 MG 1.082
Folic Acid 5 MG 3.279
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 427.085
Metoprolol Tartrate 1 MG 0.128
Rifampin 600 MG 94.76
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.445
Sulfamethoxazole-Trimethoprim 400-80 MG 0.629

ASP (Average Sale Price) Drug Pricing History