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 17 * 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
J3246 - Injection, tirofiban hcl, 0.25 mg 0.25 MG 3.622 - - - - - -
J3247 - Injection, secukinumab, intravenous, 1 mg 1 MG 17.72 - - - - - -
J3250 - Injection, trimethobenzamide hcl, up to 200 mg 200 MG 50.95 - - - - - -
J3260 - Injection, tobramycin sulfate, up to 80 mg 80 MG 1.966 - - - - - -
J3262 - Injection, tocilizumab, 1 mg 1 MG 5.966 - - - - - -
J3263 - Injection, toripalimab-tpzi, 1 mg 1 MG 39.318 - - - - - -
J3285 - Injection, treprostinil, 1 mg 1 MG 55.946 - - - - - -
J3299 - Injection, triamcinolone acetonide (xipere), 1 mg 1 MG 48.422 - - - - - -
J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg 10 MG 0.898 - - - - - -
J3304 - Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg 1 MG 17.998 - - - - - -
J3315 - Injection, triptorelin pamoate, 3.75 mg 3.75 MG 481.294 - - - - - -
J3357 - Ustekinumab, for subcutaneous injection, 1 mg 1 MG 155.883 - - - - - -
J3358 - Ustekinumab, for intravenous injection, 1 mg 1 MG 12.759 - - - - - -
J3360 - Injection, diazepam, up to 5 mg 5 MG 8.547 - - - - - -
J3370 - Injection, vancomycin hcl, 500 mg 500 MG 1.863 - - - - - -
J3371 - Injection, vancomycin hcl (mylan), not therapeutically equivalent to j3370, 500 mg 500 MG 6.433 - - - - - -
J3372 - Injection, vancomycin hcl (xellia), not therapeutically equivalent to j3370, 500 mg 500 MG 6.379 - - - - - -
J3380 - Injection, vedolizumab, intravenous, 1 mg 1 MG 21.67 - - - - - -
J3385 - Injection, velaglucerase alfa, 100 units 100 UNITS 374.019 - - - - - -
J3396 - Injection, verteporfin, 0.1 mg 0.1 MG 11.503 - - - - - -
J3401 - Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml 0.1 ML 1016.784 - - - - - -
J3410 - Injection, hydroxyzine hcl, up to 25 mg 25 MG 12.31 - - - - - -
J3411 - Injection, thiamine hcl, 100 mg 100 MG 1.764 - - - - - -
J3415 - Injection, pyridoxine hcl, 100 mg 100 MG 15.779 - - - - - -
J3420 - Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 1000 MCG 1.271 - - - - - -
* 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