ASP Drug Pricing - (1st Quarter)
January 2025
Payment Allowance Limits for Medicare Part B Drugs

  • 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 10 * 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
J1576 - Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg 500 MG 69.098 - - - - - -
J1580 - Injection, garamycin, gentamicin, up to 80 mg 80 MG 2.47 - - - - - -
J1596 - Injection, glycopyrrolate, 0.1 mg 0.1 MG 0.576 - - - - - -
J1598 - Injection, glycopyrrolate (fresenius kabi), not therapeutically equivalent to j1596, 0.1 mg 0.1 MG 2.019 - - - - - -
J1602 - Injection, golimumab, 1 mg, for intravenous use 1 MG 10.536 - - - - - -
J1610 - Injection, glucagon hydrochloride, per 1 mg 1 MG 184.179 - - - - - -
J1611 - Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg 1 MG 111.908 - - - - - -
J1626 - Injection, granisetron hydrochloride, 100 mcg 100 MCG 0.227 - - - - - -
J1627 - Injection, granisetron, extended-release, 0.1 mg 0.1 MG 5.514 - - - - - -
J1628 - Injection, guselkumab, 1 mg 1 MG 73.523 - - - - - -
J1630 - Injection, haloperidol, up to 5 mg 5 MG 1.207 - - - - - -
J1631 - Injection, haloperidol decanoate, per 50 mg 50 MG 5.547 - - - - - -
J1640 - Injection, hemin, 1 mg 1 MG 33.122 - - - - - -
J1642 - Injection, heparin sodium, (heparin lock flush), per 10 units 10 UNITS 0.018 - - - - - -
J1643 - Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units 1000 UNITS 3.519 - - - - - -
J1644 - Injection, heparin sodium, per 1000 units 1000 UNITS 0.202 - - - - - -
J1645 - Injection, dalteparin sodium, per 2500 iu 2500 IU 13.864 - - - - - -
J1650 - Injection, enoxaparin sodium, 10 mg 10 MG 0.564 - - - - - -
J1652 - Injection, fondaparinux sodium, 0.5 mg 0.5 MG 0.672 - - - - - -
J1670 - Injection, tetanus immune globulin, human, up to 250 units 250 UNITS 572.068 - - - - - -
J1720 - Injection, hydrocortisone sodium succinate, up to 100 mg 100 MG 20.939 - - - - - -
J1740 - Injection, ibandronate sodium, 1 mg 1 MG 25.358 - - - - - -
J1741 - Injection, ibuprofen, 100 mg 100 MG 2.965 - - - - - -
J1743 - Injection, idursulfase, 1 mg 1 MG 542.221 - - - - - -
J1745 - Injection, infliximab, excludes biosimilar, 10 mg 10 MG 30.525 - - - - - -
* 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