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 14 * 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
J2403 - Chloroprocaine hcl ophthalmic, 3% gel, 1 mg 1 MG 0.607 - - - - - -
J2404 - Injection, nicardipine, 0.1 mg 0.1 MG 0.077 - - - - - -
J2405 - Injection, ondansetron hydrochloride, per 1 mg 1 MG 0.09 - - - - - -
J2406 - Injection, oritavancin (kimyrsa), 10 mg 10 MG 43.324 - - - - - -
J2407 - Injection, oritavancin (orbactiv), 10 mg 10 MG 28.532 - - - - - -
J2425 - Injection, palifermin, 50 micrograms 50 MCG 33.991 - - - - - -
J2426 - Injection, paliperidone palmitate extended release (invega sustenna), 1 mg 1 MG 14.733 - - - - - -
J2427 - Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg 1MG 12.622 - - - - - -
J2430 - Injection, pamidronate disodium, per 30 mg 30 MG 12.583 - - - - - -
J2469 - Injection, palonosetron hcl, 25 mcg 25 MCG 0.590337228397608 - - - - - -
J2501 - Injection, paricalcitol, 1 mcg 1 MCG 0.9 - - - - - -
J2506 - Injection, pegfilgrastim, excludes biosimilar, 0.5 mg 0.5 MG 19.981 - - - - - -
J2507 - Injection, pegloticase, 1 mg 1 MG 3550.048 - - - - - -
J2508 - Injection, pegunigalsidase alfa-iwxj, 1 mg 1 MG 226.793 - - - - - -
J2540 - Injection, penicillin g potassium, up to 600,000 units 600000 UNITS 0.749 - - - - - -
J2543 - Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 1.125 GM 1.135 - - - - - -
J2545 - Pentamidine isethionate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 300 mg 300 MG 79.385 - - - - - -
J2550 - Injection, promethazine hcl, up to 50 mg 50 MG 3.569 - - - - - -
J2560 - Injection, phenobarbital sodium, up to 120 mg 120 MG 30.756 - - - - - -
J2562 - Injection, plerixafor, 1 mg 1 MG 37.078 - - - - - -
J2597 - Injection, desmopressin acetate, per 1 mcg 1 MCG 4.95 - - - - - -
J2598 - Injection, vasopressin, 1 unit 1 UNIT 1.631 - - - - - -
J2599 - Injection, vasopressin (american regent), not therapeutically equivalent to j2598, 1 unit 1 UNIT 1.201 - - - - - -
J2601 - Injection, vasopressin (baxter), 1 unit 1 UNIT 3.634 - - - - - -
J2675 - Injection, progesterone, per 50 mg 50 MG 0.894 - - - - - -
* 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