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 11 * 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
J1746 - Injection, ibalizumab-uiyk, 10 mg 10 MG 77.133 - - - - - -
J1747 - Injection, spesolimab-sbzo, 1 mg 1 MG 61.428 - - - - - -
J1748 - Injection, infliximab-dyyb (zymfentra), 10 mg 10 MG 261.226 - - - - - -
J1750 - Injection, iron dextran, 50 mg 50 MG 17.404 - - - - - -
J1756 - Injection, iron sucrose, 1 mg 1 MG 0.226 - - - - - -
J1786 - Injection, imiglucerase, 10 units 10 UNITS 43.381 - - - - - -
J1805 - Injection, esmolol hydrochloride, 10 mg 10 MG 0.211 - - - - - -
J1806 - Injection, esmolol hydrochloride (wg critical care), not therapeutically equivalent to j1805, 10 mg 10 MG 0.358 - - - - - -
J1811 - Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 7.9 - - - - - -
J1813 - Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 15.476 - - - - - -
J1817 - Insulin for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 2.382 - - - - - -
J1823 - Injection, inebilizumab-cdon, 1 mg 1 MG 484.403 - - - - - -
J1836 - Injection, metronidazole, 10 mg 10 MG 0.025 - - - - - -
J1885 - Injection, ketorolac tromethamine, per 15 mg 15 MG 0.751 - - - - - -
J1920 - Injection, labetalol hydrochloride, 5 mg 5 MG 0.294 - - - - - -
J1921 - Injection, labetalol hydrochloride (hikma), not therapeutically equivalent to j1920, 5 mg 5 MG 1.382 - - - - - -
J1930 - Injection, lanreotide, 1 mg 1 MG 44.983 - - - - - -
J1931 - Injection, laronidase, 0.1 mg 0.1 MG 38.616 - - - - - -
J1932 - Injection, lanreotide, (cipla), 1 mg 1 MG 30.682 - - - - - -
J1939 - Injection, bumetanide, 0.5 mg 0.5 MG 0.579 - - - - - -
J1940 - Injection, furosemide, up to 20 mg 20 MG 0.386 - - - - - -
J1943 - Injection, aripiprazole lauroxil, (aristada initio), 1 mg 1 MG 3.131 - - - - - -
J1944 - Injection, aripiprazole lauroxil, (aristada), 1 mg 1 MG 3.233 - - - - - -
J1950 - Injection, leuprolide acetate (for depot suspension), per 3.75 mg 3.75 MG 1666.776 - - - - - -
J1951 - Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg 0.25 MG 136.481 - - - - - -
* 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