HCPCS ·CODES

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 33 * 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
`Q5101` - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram	1 MCG	0.357	-	-	-	-	-	-
`Q5103` - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg	10 MG	11.55	-	-	-	-	-	-
`Q5104` - Injection, infliximab-abda, biosimilar, (renflexis), 10 mg	10 MG	26.263	-	-	-	-	-	-
`Q5105` - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units	100 UNITS	0.747	-	-	-	-	-	-
`Q5106` - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units	1000 UNITS	7.469	-	-	-	-	-	-
`Q5107` - Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg	10 MG	28.727	-	-	-	-	-	-
`Q5108` - Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg	0.5 MG	125.304	-	-	-	-	-	-
`Q5110` - Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram	1 MCG	0.289	-	-	-	-	-	-
`Q5111` - Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg	0.5 MG	135.55	-	-	-	-	-	-
`Q5112` - Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg	10 MG	26.369	-	-	-	-	-	-
`Q5113` - Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg	10 MG	71.978	-	-	-	-	-	-
`Q5114` - Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg	10 MG	51.84	-	-	-	-	-	-
`Q5115` - Injection, rituximab-abbs, biosimilar, (truxima), 10 mg	10 MG	31.833	-	-	-	-	-	-
`Q5116` - Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg	10 MG	18.969	-	-	-	-	-	-
`Q5117` - Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg	10 MG	34.688	-	-	-	-	-	-
`Q5118` - Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg	10 MG	23	-	-	-	-	-	-
`Q5119` - Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg	10 MG	23.589	-	-	-	-	-	-
`Q5120` - Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mg	0.5 MG	24.711	-	-	-	-	-	-
`Q5121` - Injection, infliximab-axxq, biosimilar, (avsola), 10 mg	10 MG	19.825	-	-	-	-	-	-
`Q5122` - Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg	0.5 MG	117.01	-	-	-	-	-	-
`Q5123` - Injection, rituximab-arrx, biosimilar, (riabni), 10 mg	10 MG	36.776	-	-	-	-	-	-
`Q5124` - Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg	0.1 MG	169.199	-	-	-	-	-	-
`Q5125` - Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram	1 MCG	0.451	-	-	-	-	-	-
`Q5126` - Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg	10 MG	58.232	-	-	-	-	-	-
`Q5127` - Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg	0.5 MG	298.305	-	-	-	-	-	-
* 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