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 34 * 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
Q4263 - Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1712.999 - - - - - -
Q4264 - Cocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 478.06 - - - - - -
Q4265 - Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1750.263 - - - - - -
Q4266 - Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 989.673 - - - - - -
Q4267 - Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 274.606 - - - - - -
Q4269 - Surgraft xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2862 - - - - - -
Q4270 - Complete sl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3370.8 - - - - - -
Q4271 - Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1399.124 - - - - - -
Q4274 - Esano ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1838.291 - - - - - -
Q4275 - Esano aca, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2676.5 - - - - - -
Q4276 - Orion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 464.342 - - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 246.046 - - - - - -
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 3246.048 - - - - - -
Q4281 - Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 560.296 - - - - - -
Q4282 - Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 487.314 - - - - - -
Q4283 - Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 550.643 - - - - - -
Q4289 - Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1602.229 - - - - - -
Q4290 - Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1841.001 - - - - - -
Q4293 - Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1584.7 - - - - - -
Q4294 - Amnio quad-core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2650 - - - - - -
Q4295 - Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2332 - - - - - -
Q4296 - Rebound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1476.13 - - - - - -
Q4297 - Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1748.223 - - - - - -
Q4298 - Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2279 - - - - - -
* 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