ASP Drug Pricing - (2nd Quarter)
April 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2024 (4th Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 12 * Effective April 1, 2025 through June 30, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J1813 - Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 15.328 - - - - - -
J1817 - Insulin for administration through dme (i.e., insulin pump) per 50 units 50 UNITS 2.491 - - - - - -
J1823 - Injection, inebilizumab-cdon, 1 mg 1 MG 484.403 - - - - - -
J1836 - Injection, metronidazole, 10 mg 10 MG 0.026 - - - - - -
J1885 - Injection, ketorolac tromethamine, per 15 mg 15 MG 0.501 - - - - - -
J1920 - Injection, labetalol hydrochloride, 5 mg 5 MG 0.419 - - - - - -
J1921 - Injection, labetalol hydrochloride (hikma), not therapeutically equivalent to j1920, 5 mg 5 MG 1.382 - - - - - -
J1930 - Injection, lanreotide, 1 mg 1 MG 39.551 - - - - - -
J1931 - Injection, laronidase, 0.1 mg 0.1 MG 38.605 - - - - - -
J1932 - Injection, lanreotide, (cipla), 1 mg 1 MG 25.422 - - - - - -
J1938 - Injection, furosemide, 1 mg 1 MG 0.02 - - - - - -
J1939 - Injection, bumetanide, 0.5 mg 0.5 MG 0.569 - - - - - -
J1943 - Injection, aripiprazole lauroxil, (aristada initio), 1 mg 1 MG 3.143 - - - - - -
J1944 - Injection, aripiprazole lauroxil, (aristada), 1 mg 1 MG 3.259 - - - - - -
J1950 - Injection, leuprolide acetate (for depot suspension), per 3.75 mg 3.75 MG 1670.296 - - - - - -
J1951 - Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg 0.25 MG 134.256 - - - - - -
J1952 - Leuprolide injectable, camcevi, 1 mg 1 mg 52.378 - - - - - -
J1953 - Injection, levetiracetam, 10 mg 10 MG 0.052 - - - - - -
J1954 - Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg 7.5 MG 220.743 - - - - - -
J1955 - Injection, levocarnitine, per 1 gm 1 GM 24.376 - - - - - -
J1956 - Injection, levofloxacin, 250 mg 250 MG 1.025 - - - - - -
J1961 - Injection, lenacapavir (only for use as hiv treatment), 1 mg 1 MG 22.03 - - - - - -
J2002 - Injection, lidocaine hcl in 5% dextrose, 1 mg 1 MG 0.003 - - - - - -
J2010 - Injection, lincomycin hcl, up to 300 mg 300 MG 6.237 - - - - - -
J2020 - Injection, linezolid, 200 mg 200 MG 3.472 - - - - - -
* Effective April 1, 2025 through June 30, 2025

Drugs not otherwise classified - April 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2025 through June 30, 2025

Drug name Dosage Payment limit Notes
Diltiazem Hydrochloride 5 MG 0.416
Metoprolol Tartrate 1 MG 0.123
Vasopressin (Long Grove) 1 UNIT 3.272 Added April 2025

ASP (Average Sale Price) Drug Pricing History