ASP Drug Pricing - (2nd Quarter)
April 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2024 (4th 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 32 * Effective April 1, 2025 through June 30, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 262.929 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 92.651 - - - - - -
Q4161 - Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1853.655 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 182.181 - - - - - -
Q4164 - Helicoll, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 322.151 - - - - - -
Q4166 - Cytal, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 21.495 - - - - - -
Q4170 - Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 444.74 - - - - - -
Q4171 - Interfyl, 1 mg 1 MG 12.125 - - - - - -
Q4173 - Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 360.508 - - - - - -
Q4175 - Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 68.556 - - - - - -
Q4178 - Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 92.03 - - - - - -
Q4180 - Revita, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1030.144 - - - - - -
Q4184 - Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 80.04 - - - - - -
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 247.017 - - - - - -
Q4188 - Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 493.303 - - - - - -
Q4190 - Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 177.494 - - - - - -
Q4191 - Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 940.152 - - - - - -
Q4193 - Coll-e-derm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1608.269 - - - - - -
Q4194 - Novachor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 719.368 - - - - - -
Q4195 - Puraply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 100.174 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 105.464 - - - - - -
Q4197 - Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 73.535 - - - - - -
Q4199 - Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 332.422 - - - - - -
Q4201 - Matrion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 86.346 - - - - - -
* Effective April 1, 2025 through June 30, 2025

Drugs not otherwise classified - April 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2025 through June 30, 2025

Drug name Dosage Payment limit Notes
Diltiazem Hydrochloride 5 MG 0.416
Metoprolol Tartrate 1 MG 0.123
Vasopressin (Long Grove) 1 UNIT 3.272 Added April 2025

ASP (Average Sale Price) Drug Pricing History