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 27 * 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
J9308 - Injection, ramucirumab, 5 mg 5 MG 72.912 - - - - - -
J9309 - Injection, polatuzumab vedotin-piiq, 1 mg 1 MG 132.916 - - - - - -
J9311 - Injection, rituximab 10 mg and hyaluronidase 10 mg 36.576 - - - - - -
J9312 - Injection, rituximab, 10 mg 10 MG 76.73 - - - - - -
J9314 - Injection, pemetrexed (teva), not therapeutically equivalent to j9305, 10 mg 10 MG 7.135 - - - - - -
J9316 - Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg 10 MG 63.88 - - - - - -
J9317 - Injection, sacituzumab govitecan-hziy, 2.5 mg 2.5 MG 35.438 - - - - - -
J9319 - Injection, romidepsin, lyophilized, 0.1 mg 0.1 MG 30.392 - - - - - -
J9321 - Injection, epcoritamab-bysp, 0.16 mg 0.16 MG 55.186 - - - - - -
J9324 - Injection, pemetrexed (pemrydi rtu), 10 mg 10 MG 82.135 - - - - - -
J9325 - Injection, talimogene laherparepvec, per 1 million plaque forming units 1 million PFU 70.367 - - - - - -
J9328 - Injection, temozolomide, 1 mg 1 MG 10.409 - - - - - -
J9330 - Injection, temsirolimus, 1 mg 1 MG 29.518 - - - - - -
J9331 - Injection, sirolimus protein-bound particles, 1 mg 1 MG 117.449 - - - - - -
J9332 - Injection, efgartigimod alfa-fcab, 2mg 2 MG 32.449 - - - - - -
J9333 - Injection, rozanolixizumab-noli, 1 mg 1 MG 22.821 - - - - - -
J9334 - Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc 2 MG 33.101 - - - - - -
J9340 - Injection, thiotepa, 15 mg 15 MG 221.753 - - - - - -
J9345 - Injection, retifanlimab-dlwr, 1 mg 1 MG 29.264 - - - - - -
J9347 - Injection, tremelimumab-actl, 1 mg 1 MG 138.432 - - - - - -
J9348 - Injection, naxitamab-gqgk, 1 mg 1 MG 642.289 - - - - - -
J9349 - Injection, tafasitamab-cxix, 2 mg 2 MG 13.966 - - - - - -
J9350 - Injection, mosunetuzumab-axgb, 1 mg 1 MG 641.067 - - - - - -
J9351 - Injection, topotecan, 0.1 mg 0.1 MG 1.784 - - - - - -
J9352 - Injection, trabectedin, 0.1 mg 0.1 MG 362.75 - - - - - -
* 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