ASP Drug Pricing - (3rd Quarter)
July 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2025 (1st 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 36 * Effective Jul 1, 2025 through Sep 30, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4310 - Procenta, per 100 mg 100 MG 1317.357 - - - - - -
Q4313 - Dermabind fm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3520.688 - - - - - -
Q4316 - Amchoplast, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 4415.969 - - - - - -
Q4322 - Caregraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1791.291 - - - - - -
Q4323 - Alloply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1574.542 - - - - - -
Q4325 - Acapatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2045.856 - - - - - -
Q4326 - Woundplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1082.95 - - - - - -
Q4328 - Most, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3673.308 - - - - - -
Q4331 - Axolotl graft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1637.549 - - - - - -
Q4332 - Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1683.468 - - - - - -
Q4339 - Artacent vericlen, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2055.34 - - - - - -
Q4341 - Simplimax, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3071.281 - - - - - -
Q4342 - Theramend, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2127.108 - - - - - -
Q4343 - Dermacyte ac matrix amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2952.1 - - - - - -
Q4344 - Tri-membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2689.477 - - - - - -
Q4357 - Xwrap plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 4770 - - - - - -
Q4361 - Epixpress, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1590 - - - - - -
Q4367 - Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 530 - - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.367 - - - - - -
Q5103 - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 10 MG 19.679 - - - - - -
Q5104 - Injection, infliximab-abda, biosimilar, (renflexis), 10 mg 10 MG 25.053 - - - - - -
Q5105 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units 100 UNITS 0.757 - - - - - -
Q5106 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units 1000 UNITS 7.566 - - - - - -
Q5107 - Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg 10 MG 28.848 - - - - - -
Q5108 - Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg 0.5 MG 103.705 - - - - - -
* Effective Jul 1, 2025 through Sep 30, 2025

Drugs not otherwise classified - July 2025

 

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

Drug name Dosage Payment limit Notes
Vasopressin (Long Grove) 1 UNIT 2.796

ASP (Average Sale Price) Drug Pricing History