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 25 * 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
J9196 - Injection, gemcitabine hydrochloride (accord), not therapeutically equivalent to j9201, 200 mg 200 MG 9.337 - - - - - -
J9200 - Injection, floxuridine, 500 mg 500 MG 3989.64 - - - - - -
J9201 - Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg 200 MG 2.865 - - - - - -
J9202 - Goserelin acetate implant, per 3.6 mg 3.6 MG 703.06 - - - - - -
J9203 - Injection, gemtuzumab ozogamicin, 0.1 mg 0.1 MG 233.119 - - - - - -
J9204 - Injection, mogamulizumab-kpkc, 1 mg 1 MG 243.317 - - - - - -
J9205 - Injection, irinotecan liposome, 1 mg 1 MG 64.215 - - - - - -
J9206 - Injection, irinotecan, 20 mg 20 MG 1.9738431089122 - - - - - -
J9207 - Injection, ixabepilone, 1 mg 1 MG 136.427 - - - - - -
J9208 - Injection, ifosfamide, 1 gram 1 GM 25.067 - - - - - -
J9209 - Injection, mesna, 200 mg 200 MG 1.58 - - - - - -
J9210 - Injection, emapalumab-lzsg, 1 mg 1 MG 376.569 - - - - - -
J9211 - Injection, idarubicin hydrochloride, 5 mg 5 MG 46.801 - - - - - -
J9217 - Leuprolide acetate (for depot suspension), 7.5 mg 7.5 MG 180.794 - - - - - -
J9218 - Leuprolide acetate, per 1 mg 1 MG 8.913 - - - - - -
J9223 - Injection, lurbinectedin, 0.1 mg 0.1 MG 204.899 - - - - - -
J9226 - Histrelin implant (supprelin la), 50 mg 50 MG 45261.796 - - - - - -
J9227 - Injection, isatuximab-irfc, 10 mg 10 MG 79.347 - - - - - -
J9228 - Injection, ipilimumab, 1 mg 1 MG 180.051 - - - - - -
J9229 - Injection, inotuzumab ozogamicin, 0.1 mg 0.1 MG 2658.129 - - - - - -
J9245 - Injection, melphalan hydrochloride, not otherwise specified, 50 mg 50 MG 133.694 - - - - - -
J9246 - Injection, melphalan (evomela), 1 mg 1 MG 18.003 - - - - - -
J9248 - Injection, melphalan (hepzato), 1 mg 1 MG 773.8 - - - - - -
J9260 - Injection, methotrexate sodium, 50 mg 50 MG 3.373 - - - - - -
J9261 - Injection, nelarabine, 50 mg 50 MG 74.755 - - - - - -
* 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