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 20 * 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
J7212 - Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram 1 MCG 2.349 - - - - - - 1
J7213 - Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. 1 IU 2.202 - - - - - - 1
J7214 - Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii i.u. 1 IU 4.639 - - - - - - 1
J7308 - Aminolevulinic acid hcl for topical administration, 20%, single unit dosage form (354 mg) 354 MG 395.264 - - - - - -
J7311 - Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01 mg 0.01 MG 333.233 - - - - - -
J7312 - Injection, dexamethasone, intravitreal implant, 0.1 mg 0.1 MG 205.557 - - - - - -
J7313 - Injection, fluocinolone acetonide, intravitreal implant (iluvien), 0.01 mg 0.01 MG 493.684 - - - - - -
J7314 - Injection, fluocinolone acetonide, intravitreal implant (yutiq), 0.01 mg 0.01 MG 525.893 - - - - - -
J7318 - Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg 1 MG 6.702 - - - - - -
J7320 - Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg 1 MG 6.172 - - - - - -
J7321 - Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose per dose 73.026 - - - - - -
J7322 - Hyaluronan or derivative, hymovis or hymovis one, for intra-articular injection, 1 mg 1 MG 17.415 - - - - - -
J7323 - Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose per dose 120.682 - - - - - -
J7324 - Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose PER DOSE 92.136 - - - - - -
J7325 - Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg 1 MG 9.163 - - - - - -
J7326 - Hyaluronan or derivative, gel-one, for intra-articular injection, per dose per dose 526.376 - - - - - -
J7327 - Hyaluronan or derivative, monovisc, for intra-articular injection, per dose PER DOSE 564.654 - - - - - -
J7328 - Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg 0.1 MG 0.559 - - - - - -
J7329 - Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg 1 MG 6.103 - - - - - -
J7331 - Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg 1 MG 8.903 - - - - - -
J7332 - Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg 1 MG 10.094 - - - - - -
J7336 - Capsaicin 8% patch, per square centimeter 1 SQ CM 3.327 - - - - - -
J7340 - Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml 100 ML 235.948 - - - - - -
J7345 - Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg 10 MG 1.722 - - - - - -
J7351 - Injection, bimatoprost, intracameral implant, 1 microgram 1 MCG 209.889 - - - - - -
* 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