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 30 * 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
Q4127 - Talymed, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 68.487 - - - - - -
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.593 - - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 136.851 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 138.753 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 116.681 - - - - - -
Q4138 - Biodfence dryflex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 93.566 - - - - - -
Q4140 - Biodfence, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 171.809 - - - - - -
Q4141 - Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 37.984 - - - - - -
Q4148 - Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 127.505 - - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 86.699 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 143.415 - - - - - -
Q4152 - Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 52.05 - - - - - -
Q4153 - Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 232.713 - - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 144.357 - - - - - -
Q4155 - Neoxflo or clarixflo, 1 mg 1 MG 28.723 - - - - - -
Q4156 - Neox 100 or clarix 100, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 64.045 - - - - - -
Q4158 - Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 75.455 - - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 263.351 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 93.929 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 182.181 - - - - - -
Q4166 - Cytal, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 20.556 - - - - - -
Q4171 - Interfyl, 1 mg 1 MG 11.913 - - - - - -
Q4175 - Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 69.044 - - - - - -
Q4178 - Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 87.176 - - - - - -
Q4184 - Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 624.34 - - - - - -
* 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