ASP Drug Pricing - (3rd Quarter)
July 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2025 (1st 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 Jul 1, 2025 through Sep 30, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J1110 - Injection, dihydroergotamine mesylate, per 1 mg 1 MG 97.073 - - - - - -
J1120 - Injection, acetazolamide sodium, up to 500 mg 500 MG 17.226 - - - - - -
J1160 - Injection, digoxin, up to 0.5 mg 0.5 MG 4.001 - - - - - -
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 4968.58 - - - - - -
J1163 - Injection, diltiazem hydrochloride, 0.5 mg 0.5 MG 0.037 - - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.657 - - - - - -
J1171 - Injection, hydromorphone, 0.1 mg 0.1 MG 0.085 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 32.085 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.904 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 16.397 - - - - - -
J1203 - Injection, cipaglucosidase alfa-atga, 5 mg 5 MG 89.797 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 40.382 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 742.895 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 22.914 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 7.741 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 3.863 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 7.977 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.656 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.374 - - - - - -
J1271 - Injection, doxycycline hyclate, 1 mg 1 MG 0.116 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 579.987 - - - - - -
J1299 - Injection, eculizumab, 2 mg 2 MG 44.771 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 18.837 - - - - - -
J1302 - Injection, sutimlimab-jome, 10 mg 10 MG 18.109 - - - - - -
J1303 - Injection, ravulizumab-cwvz, 10 mg 10 MG 225.193 - - - - - -
* Effective Jul 1, 2025 through Sep 30, 2025

Drugs not otherwise classified - July 2025

 

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

Drug name Dosage Payment limit Notes
Vasopressin (Long Grove) 1 UNIT 2.796

ASP (Average Sale Price) Drug Pricing History