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 29 * 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
Q2041 - Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION CAR T CELLS 489517.151 - - - - - -
Q2042 - Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose up to 600 million CAR-positive viable T cells 565623.836 - - - - - -
Q2043 - Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion Per infusion (minimum 50 million cells) 55536.498 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 136.046 - - - - - -
Q2053 - Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR POSITIVE VIABLE T CEL 488051.51 - - - - - -
Q2054 - Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose Up to 110 million CAR-positive viable T cells, per therapeutic d 516485.967 - - - - - -
Q2055 - Idecabtagene vicleucel, up to 510 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 510 MILLION AUTOLOGOUS ANTI-BCMA CAR-POSITIVE VIABLE T CEL 528312.427 - - - - - -
Q2056 - Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose up to 100 million autologous b-cell maturation antigen (bcma) di 551318.337 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 55.62 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 148.238 - - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.646 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.476 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.07 - - - - - -
Q4103 - Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.481 - - - - - -
Q4104 - Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 52.396 - - - - - -
Q4105 - Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.277 - - - - - -
Q4108 - Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 44.841 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 65.405 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.326 - - - - - -
Q4114 - Integra flowable wound matrix, injectable, 1 cc 1 CC 1600.605 - - - - - -
Q4115 - Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 15.151 - - - - - -
Q4118 - Matristem micromatrix, 1 mg 1 MG 2.543 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 48.454 - - - - - -
Q4124 - Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 10.216 - - - - - -
Q4126 - Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 59.544 - - - - - -
* 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