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 35 * 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
Q4299 - Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2597 - - - - - -
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 1896.761 - - - - - -
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 3397.401 - - - - - -
Q4304 - Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 753.463 - - - - - -
Q4309 - Via matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1323.965 - - - - - -
Q4310 - Procenta, per 100 mg 100 MG 2213.138 - - - - - -
Q4313 - Dermabind fm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3337.231 - - - - - -
Q4319 - Sanograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2650 - - - - - -
Q4322 - Caregraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1855 - - - - - -
Q4323 - Alloply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1643 - - - - - -
Q4325 - Acapatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2067 - - - - - -
Q4328 - Most, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3710 - - - - - -
Q4332 - Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1696.165 - - - - - -
Q4343 - Dermacyte ac matrix amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2952.1 - - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.333 - - - - - -
Q5103 - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 10 MG 15.912 - - - - - -
Q5104 - Injection, infliximab-abda, biosimilar, (renflexis), 10 mg 10 MG 27.845 - - - - - -
Q5105 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units 100 UNITS 0.707 - - - - - -
Q5106 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units 1000 UNITS 7.07 - - - - - -
Q5107 - Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg 10 MG 29.824 - - - - - -
Q5108 - Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg 0.5 MG 112.895 - - - - - -
Q5110 - Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram 1 MCG 0.287 - - - - - -
Q5111 - Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg 0.5 MG 163.604 - - - - - -
* 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