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 26 * 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
J9263 - Injection, oxaliplatin, 0.5 mg 0.5 MG 0.075 - - - - - -
J9264 - Injection, paclitaxel protein-bound particles, 1 mg 1 MG 13.536 - - - - - -
J9266 - Injection, pegaspargase, per single dose vial 1 EA 27070.534 - - - - - -
J9267 - Injection, paclitaxel, 1 mg 1 MG 0.109 - - - - - -
J9268 - Injection, pentostatin, 10 mg 10 MG 2732.531 - - - - - -
J9269 - Injection, tagraxofusp-erzs, 10 micrograms 10 MCG 338.89 - - - - - -
J9271 - Injection, pembrolizumab, 1 mg 1 MG 57.603 - - - - - -
J9272 - Injection, dostarlimab-gxly, 10 mg 10 MG 240.064 - - - - - -
J9273 - Injection, tisotumab vedotin-tftv, 1 mg 1 MG 181.874 - - - - - -
J9274 - Injection, tebentafusp-tebn, 1 microgram 1 MCG 214.756 - - - - - -
J9280 - Injection, mitomycin, 5 mg 5 MG 46.348 - - - - - -
J9281 - Mitomycin pyelocalyceal instillation, 1 mg 1 MG 311.356 - - - - - -
J9286 - Injection, glofitamab-gxbm, 2.5 mg 2.5 MG 2770.911 - - - - - -
J9293 - Injection, mitoxantrone hydrochloride, per 5 mg 5 MG 60.819 - - - - - -
J9294 - Injection, pemetrexed (hospira), not therapeutically equivalent to j9305, 10 mg 10 MG 2.565276388 - - - - - -
J9295 - Injection, necitumumab, 1 mg 1 MG 5.731 - - - - - -
J9297 - Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg 10 MG 1.529 - - - - - -
J9298 - Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg 3 mg/1 mg 193.864 - - - - - -
J9299 - Injection, nivolumab, 1 mg 1 MG 32.296 - - - - - -
J9301 - Injection, obinutuzumab, 10 mg 10 MG 74.827 - - - - - -
J9303 - Injection, panitumumab, 10 mg 10 MG 165.713 - - - - - -
J9304 - Injection, pemetrexed (pemfexy), 10 mg 10 MG 52.695 - - - - - -
J9305 - Injection, pemetrexed, not otherwise specified, 10 mg 10 MG 5.272 - - - - - -
J9306 - Injection, pertuzumab, 1 mg 1 MG 16.19 - - - - - -
J9307 - Injection, pralatrexate, 1 mg 1 MG 373.768 - - - - - -
* 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