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 18 * 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
J3250 - Injection, trimethobenzamide hcl, up to 200 mg 200 MG 50.038 - - - - - -
J3260 - Injection, tobramycin sulfate, up to 80 mg 80 MG 1.595 - - - - - -
J3262 - Injection, tocilizumab, 1 mg 1 MG 5.881 - - - - - -
J3263 - Injection, toripalimab-tpzi, 1 mg 1 MG 39.096 - - - - - -
J3285 - Injection, treprostinil, 1 mg 1 MG 56.834 - - - - - -
J3299 - Injection, triamcinolone acetonide (xipere), 1 mg 1 MG 48.231 - - - - - -
J3300 - Injection, triamcinolone acetonide, preservative free, 1 mg 1 MG 25.016 - - - - - -
J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg 10 MG 0.87 - - - - - -
J3304 - Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg 1 MG 18.007 - - - - - -
J3315 - Injection, triptorelin pamoate, 3.75 mg 3.75 MG 471.625 - - - - - -
J3316 - Injection, triptorelin, extended-release, 3.75 mg 3.75 MG 3506.041 - - - - - -
J3358 - Ustekinumab, for intravenous injection, 1 mg 1 MG 12.808 - - - - - -
J3360 - Injection, diazepam, up to 5 mg 5 MG 5.787 - - - - - -
J3370 - Injection, vancomycin hcl, 500 mg 500 MG 1.949 - - - - - -
J3371 - Injection, vancomycin hcl (mylan), not therapeutically equivalent to j3370, 500 mg 500 MG 6.309 - - - - - -
J3372 - Injection, vancomycin hcl (xellia), not therapeutically equivalent to j3370, 500 mg 500 MG 6.544 - - - - - -
J3380 - Injection, vedolizumab, intravenous, 1 mg 1 MG 21.162 - - - - - -
J3385 - Injection, velaglucerase alfa, 100 units 100 UNITS 374.36 - - - - - -
J3396 - Injection, verteporfin, 0.1 mg 0.1 MG 11.519 - - - - - -
J3401 - Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml 0.1 ML 1016.669 - - - - - -
J3410 - Injection, hydroxyzine hcl, up to 25 mg 25 MG 17.76 - - - - - -
J3411 - Injection, thiamine hcl, 100 mg 100 MG 1.757 - - - - - -
J3415 - Injection, pyridoxine hcl, 100 mg 100 MG 12.569 - - - - - -
J3420 - Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 1000 MCG 0.665 - - - - - -
J3425 - Injection, hydroxocobalamin, intramuscular, 10 mcg 10 MCG 0.008 - - - - - -
* 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