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 32 * 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
Q4256 - Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 972.834 - - - - - -
Q4257 - Relese, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 487.721 - - - - - -
Q4258 - Enverse, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 73.42 - - - - - -
Q4259 - Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1280.736 - - - - - -
Q4262 - Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 302.521 - - - - - -
Q4265 - Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2114.7 - - - - - -
Q4266 - Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 888.916 - - - - - -
Q4267 - Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 371.312 - - - - - -
Q4271 - Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1541.612 - - - - - -
Q4276 - Orion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 483.792 - - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 306.067 - - - - - -
Q4279 - Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2385 - - - - - -
Q4280 - Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2060.397 - - - - - -
Q4281 - Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 888.114 - - - - - -
Q4282 - Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 486.781 - - - - - -
Q4283 - Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 660.382 - - - - - -
Q4289 - Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1859.498 - - - - - -
Q4297 - Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1788.155 - - - - - -
Q4298 - Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2172.414 - - - - - -
Q4300 - Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2114.7 - - - - - -
Q4301 - Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1934.927 - - - - - -
Q4302 - Complete aca, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2008.7 - - - - - -
Q4303 - Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3412.785 - - - - - -
Q4304 - Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 919.993 - - - - - -
Q4310 - Procenta, per 100 mg 100 MG 2154.978 - - - - - -
* 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