ASP Drug Pricing - (1st Quarter)
January 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2024 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 31 * Effective January 1, 2025 through March 31, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 158.334 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 242.727 - - - - - -
Q4188 - Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 346.642 - - - - - -
Q4190 - Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 235.692 - - - - - -
Q4191 - Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1016.313 - - - - - -
Q4194 - Novachor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 858.919 - - - - - -
Q4195 - Puraply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 102.788 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 105.69 - - - - - -
Q4197 - Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 72.644 - - - - - -
Q4199 - Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 363.787 - - - - - -
Q4201 - Matrion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 85.034 - - - - - -
Q4203 - Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 300.181 - - - - - -
Q4205 - Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1159.614 - - - - - -
Q4217 - Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 370.863 - - - - - -
Q4222 - Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 116.964 - - - - - -
Q4225 - Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1459.55 - - - - - -
Q4229 - Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 521.027 - - - - - -
Q4231 - Corplex p, per cc 1 CC 1013.111 - - - - - -
Q4232 - Corplex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 265.144 - - - - - -
Q4234 - Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 255.135 - - - - - -
Q4235 - Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 95.148 - - - - - -
Q4236 - Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 613.603 - - - - - -
Q4238 - Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1557.992 - - - - - -
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 76.969 - - - - - -
Q4253 - Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 119.428 - - - - - -
* Effective January 1, 2025 through March 31, 2025

Drugs not otherwise classified - January 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2025 through March 31, 2025

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.33
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.783
Diltiazem Hydrochloride 5 MG 0.355
Doxycycline Hyclate 100 MG 12.599
Famotidine 10 MG 0.289
Flumazenil 0.1 MG 1.082
Folic Acid 5 MG 3.279
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 427.085
Metoprolol Tartrate 1 MG 0.128
Rifampin 600 MG 94.76
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.445
Sulfamethoxazole-Trimethoprim 400-80 MG 0.629

ASP (Average Sale Price) Drug Pricing History