ASP Drug Pricing - (4th Quarter)
October 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2025 (2nd 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 October 1, 2025 - December 31, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J1096 - Dexamethasone, lacrimal ophthalmic insert, 0.1 mg 0.1 MG 102.935 - - - - - -
J1100 - Injection, dexamethasone sodium phosphate, 1 mg 1 MG 0.094 - - - - - -
J1110 - Injection, dihydroergotamine mesylate, per 1 mg 1 MG 60.004 - - - - - -
J1120 - Injection, acetazolamide sodium, up to 500 mg 500 MG 19.842 - - - - - -
J1160 - Injection, digoxin, up to 0.5 mg 0.5 MG 9.053 - - - - - -
J1162 - Injection, digoxin immune fab (ovine), per vial PER VIAL 5168.229 - - - - - -
J1163 - Injection, diltiazem hydrochloride, 0.5 mg 0.5 MG 0.033 - - - - - -
J1165 - Injection, phenytoin sodium, per 50 mg 50 MG 0.454 - - - - - -
J1171 - Injection, hydromorphone, 0.1 mg 0.1 MG 0.095 - - - - - -
J1190 - Injection, dexrazoxane hydrochloride, per 250 mg 250 MG 63.06 - - - - - -
J1200 - Injection, diphenhydramine hcl, up to 50 mg 50 MG 0.755 - - - - - -
J1201 - Injection, cetirizine hydrochloride, 0.5 mg 0.5 MG 16.515 - - - - - -
J1203 - Injection, cipaglucosidase alfa-atga, 5 mg 5 MG 91.213 - - - - - -
J1205 - Injection, chlorothiazide sodium, per 500 mg 500 MG 39.447 - - - - - -
J1212 - Injection, dmso, dimethyl sulfoxide, 50%, 50 ml 50 ML 748.845 - - - - - -
J1230 - Injection, methadone hcl, up to 10 mg 10 MG 19.328 - - - - - -
J1240 - Injection, dimenhydrinate, up to 50 mg 50 MG 6.138 - - - - - -
J1245 - Injection, dipyridamole, per 10 mg 10 MG 8.41 - - - - - -
J1250 - Injection, dobutamine hydrochloride, per 250 mg 250 MG 7.081 - - - - - -
J1265 - Injection, dopamine hcl, 40 mg 40 MG 0.833 - - - - - -
J1270 - Injection, doxercalciferol, 1 mcg 1 MCG 0.351 - - - - - -
J1271 - Injection, doxycycline hyclate, 1 mg 1 MG 0.111 - - - - - -
J1290 - Injection, ecallantide, 1 mg 1 MG 579.965 - - - - - -
J1299 - Injection, eculizumab, 2 mg 2 MG 44.821 - - - - - -
J1301 - Injection, edaravone, 1 mg 1 MG 20.992 - - - - - -
* Effective October 1, 2025 - December 31, 2025

Drugs not otherwise classified - October 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2025 - December 31, 2025

Drug name Dosage Payment limit Notes
Vasopressin (Long Grove) 1 UNIT 2.462

ASP (Average Sale Price) Drug Pricing History