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 8 * 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
J1171 - Injection, hydromorphone, 0.1 mg 0.1 MG 0.137 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 80.956 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.661 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 15.623 - - - - - -
J1203 - Injection, cipaglucosidase alfa-atga, 5 mg 5 MG 89.846 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 32.482 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 714.724 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 20.912 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 8.346 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.836 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 8.145 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.709 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.376 - - - - - -
J1271 - Injection, doxycycline hyclate, 1 mg 1 MG 0.12 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 564.641 - - - - - -
J1299 - Injection, eculizumab, 2 mg 2 MG 44.809 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 20.405 - - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 18.127 - - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 220.317 - - - - - -
J1304 - Injection, tofersen, 1 mg 1 MG 155.337 - - - - - -
J1305 - Injection, evinacumab-dgnb, 5mg 5 MG 186.306 - - - - - -
J1306 - Injection, inclisiran, 1 mg 1 MG 12.274 - - - - - -
J1308 - Injection, famotidine, 0.25 mg 0.25 MG 0.008 - - - - - -
J1322 - Injection, elosulfase alfa, 1 mg 1 MG 293.935 - - - - - -
J1323 - Injection, elranatamab-bcmm, 1 mg 1 MG 182.98 - - - - - -
* 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