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 24 * 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
J9065 - Injection, cladribine, per 1 mg 1 MG 11.27 - - - - - -
J9071 - Injection, cyclophosphamide (auromedics), 5 mg 5 MG 0.699852478676859 - - - - - -
J9073 - Injection, cyclophosphamide (dr. reddy's), 5 mg 5 MG 2.188 - - - - - -
J9074 - Injection, cyclophosphamide (sandoz), 5 mg 5 MG 4.351 - - - - - -
J9075 - Injection, cyclophosphamide, not otherwise specified, 5 mg 5 MG 0.876 - - - - - -
J9100 - Injection, cytarabine, 100 mg 100 MG 0.791 - - - - - -
J9118 - Injection, calaspargase pegol-mknl, 10 units 10 UNIT 76.526 - - - - - -
J9119 - Injection, cemiplimab-rwlc, 1 mg 1 MG 28.206 - - - - - -
J9120 - Injection, dactinomycin, 0.5 mg 0.5 MG 324.801 - - - - - -
J9130 - Dacarbazine, 100 mg 100 MG 4.174 - - - - - -
J9144 - Injection, daratumumab, 10 mg and hyaluronidase-fihj 10 MG 51.386 - - - - - -
J9145 - Injection, daratumumab, 10 mg 10 MG 65.317 - - - - - -
J9150 - Injection, daunorubicin, 10 mg 10 MG 23.517 - - - - - -
J9153 - Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine 1 MG/2.27 MG 248.41 - - - - - -
J9155 - Injection, degarelix, 1 mg 1 MG 4.281 - - - - - -
J9171 - Injection, docetaxel, 1 mg 1 MG 0.734 - - - - - -
J9172 - Injection, docetaxel (docivyx), 1 mg 1 MG 52.211 - - - - - -
J9173 - Injection, durvalumab, 10 mg 10 MG 83.883 - - - - - -
J9176 - Injection, elotuzumab, 1 mg 1 MG 7.721 - - - - - -
J9177 - Injection, enfortumab vedotin-ejfv, 0.25 mg 0.25 MG 36.647 - - - - - -
J9178 - Injection, epirubicin hcl, 2 mg 2 MG 1.625 - - - - - -
J9179 - Injection, eribulin mesylate, 0.1 mg 0.1 MG 133.317 - - - - - -
J9181 - Injection, etoposide, 10 mg 10 MG 0.976 - - - - - -
J9185 - Injection, fludarabine phosphate, 50 mg 50 MG 168.3 - - - - - -
J9190 - Injection, fluorouracil, 500 mg 500 MG 2.23 - - - - - -
* 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