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 22 * 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
J7613 - Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 1 mg 1 MG 0.074 - - - - - -
J7614 - Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 0.5 mg 0.5 MG 0.085 - - - - - -
J7620 - Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, fda-approved final product, non-compounded, administered through dme 2.5 MG/0.5 MG 0.186 - - - - - -
J7626 - Budesonide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 0.5 mg 0.5 MG 1.412 - - - - - -
J7631 - Cromolyn sodium, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 10 milligrams 10 MG 0.214 - - - - - -
J7639 - Dornase alfa, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1 MG 53.593 - - - - - -
J7644 - Ipratropium bromide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1 MG 0.367 - - - - - -
J7674 - Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg 1 MG 1.61 - - - - - -
J7677 - Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through dme, 1 microgram 1 MCG 0.197 - - - - - -
J7682 - Tobramycin, inhalation solution, fda-approved final product, non-compounded, unit dose form, administered through dme, per 300 milligrams 300 MG 16.003 - - - - - -
J7686 - Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg 1.74 MG 760.152 - - - - - -
J8501 - Aprepitant, oral, 5 mg 5 MG 2.857 - - - - - -
J8522 - Capecitabine, oral, 50 mg 50 MG 0.04 - - - - - -
J8530 - Cyclophosphamide; oral, 25 mg 25 MG 0.836 - - - - - -
J8540 - Dexamethasone, oral, 0.25 mg 0.25 MG 0.064 - - - - - -
J8560 - Etoposide; oral, 50 mg 50 MG 76.524 - - - - - -
J8610 - Methotrexate; oral, 2.5 mg 2.5 MG 0.177 - - - - - -
J8655 - Netupitant 300 mg and palonosetron 0.5 mg, oral 0.5 MG 399.872 - - - - - -
J8670 - Rolapitant, oral, 1 mg 1 MG 1.616 - - - - - -
J8700 - Temozolomide, oral, 5 mg 5 MG 0.265 - - - - - -
J8705 - Topotecan, oral, 0.25 mg 0.25 mg 124.931 - - - - - -
J9000 - Injection, doxorubicin hydrochloride, 10 mg 10 MG 3.32 - - - - - -
J9017 - Injection, arsenic trioxide, 1 mg 1 MG 4.681 - - - - - -
J9021 - Injection, asparaginase, recombinant, (rylaze), 0.1 mg 0.1 MG 54.14 - - - - - -
J9022 - Injection, atezolizumab, 10 mg 10 MG 88.223 - - - - - -
* 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