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 18 * 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
J3425 - Injection, hydroxocobalamin, intramuscular, 10 mcg 10 MCG 0.008 - - - - - -
J3430 - Injection, phytonadione (vitamin k), per 1 mg 1 MG 2.206 - - - - - -
J3465 - Injection, voriconazole, 10 mg 10 MG 0.974 - - - - - -
J3470 - Injection, hyaluronidase, up to 150 units 150 UNITS 30.066 - - - - - -
J3473 - Injection, hyaluronidase, recombinant, 1 usp unit 1 USP UNIT 0.365 - - - - - -
J3475 - Injection, magnesium sulfate, per 500 mg 500 MG 0.489 - - - - - -
J3480 - Injection, potassium chloride, per 2 meq 2 MEQ 0.103 - - - - - -
J3485 - Injection, zidovudine, 10 mg 10 MG 1.513 - - - - - -
J3486 - Injection, ziprasidone mesylate, 10 mg 10 MG 7.191 - - - - - -
J3489 - Injection, zoledronic acid, 1 mg 1 MG 5.604 - - - - - -
J7030 - Infusion, normal saline solution , 1000 cc 1000 CC 2.504 - - - - - -
J7040 - Infusion, normal saline solution, sterile (500 ml = 1 unit) 500 ML 1.252 - - - - - -
J7042 - 5% dextrose/normal saline (500 ml = 1 unit) 500 ML 1.178 - - - - - -
J7050 - Infusion, normal saline solution, 250 cc 250 CC 0.626 - - - - - -
J7060 - 5% dextrose/water (500 ml = 1 unit) 500 ML 1.799 - - - - - -
J7070 - Infusion, d5w, 1000 cc 1000 CC 3.598 - - - - - -
J7120 - Ringers lactate infusion, up to 1000 cc 1000 CC 2.412 - - - - - -
J7170 - Injection, emicizumab-kxwh, 0.5 mg 0.5 MG 52.019 - - - - - - 1
J7171 - Injection, adamts13, recombinant-krhn, 10 iu 10 UNITS 34.571 - - - - - -
J7175 - Injection, factor x, (human), 1 i.u. 1 IU 9.533 - - - - - - 1
J7177 - Injection, human fibrinogen concentrate (fibryga), 1 mg 1 MG 1.107 - - - - - - 1
J7178 - Injection, human fibrinogen concentrate, not otherwise specified, 1 mg 1 MG 1.483 - - - - - - 1
J7179 - Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco 1 IU 1.851 - - - - - - 1
J7180 - Injection, factor xiii (antihemophilic factor, human), 1 i.u. 1 IU 10.473 - - - - - - 1
J7181 - Injection, factor xiii a-subunit, (recombinant), per iu 1 IU 17.169 - - - - - - 1
* 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