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 34 * 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
Q5128 - Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg 0.1 MG 168.744 - - - - - -
Q5129 - Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg 10 MG 52.001 - - - - - -
Q5130 - Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg 0.5 MG 183.517 - - - - - -
Q5133 - Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mg 1 MG 5.996 - - - - - -
Q5135 - Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg 1 MG 4.106 - - - - - -
Q9950 - Injection, sulfur hexafluoride lipid microspheres, per ml 1 ML 18.676 - - - - - -
Q9956 - Injection, octafluoropropane microspheres, per ml 1 ML 41.605 - - - - - -
Q9957 - Injection, perflutren lipid microspheres, per ml 1 ML 41.605 - - - - - -
Q9958 - High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml 1 ML 0.073 - - - - - -
Q9961 - High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml 1 ML 0.291 - - - - - -
Q9963 - High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml 1 ML 0.217 - - - - - -
Q9965 - Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml 1 ML 1.204 - - - - - -
Q9966 - Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml 1 ML 0.405 - - - - - -
Q9967 - Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml 1 ML 0.144 - - - - - -
Q9991 - Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg Less than or equal to 100 MG 1931.812 - - - - - -
Q9992 - Injection, buprenorphine extended-release (sublocade), greater than 100 mg Greater than 100 MG 1931.812 - - - - - -
* 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