ASP Drug Pricing - (4th Quarter)
October 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2025 (2nd 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 October 1, 2025 - December 31, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 53 - - - - - -
Q4253 - Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 75.79 - - - - - -
Q4256 - Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 735.045 - - - - - -
Q4257 - Relese, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 915.087 - - - - - -
Q4258 - Enverse, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 89.746 - - - - - -
Q4259 - Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 713.501 - - - - - -
Q4262 - Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 99.027 - - - - - -
Q4263 - Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1815.78 - - - - - -
Q4264 - Cocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 372.888 - - - - - -
Q4265 - Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1386.446 - - - - - -
Q4266 - Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 540.301 - - - - - -
Q4267 - Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 323.214 - - - - - -
Q4268 - Surgraft ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 452.707 - - - - - -
Q4269 - Surgraft xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1804.956 - - - - - -
Q4270 - Complete sl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3319.849 - - - - - -
Q4271 - Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1141.337 - - - - - -
Q4274 - Esano ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1881.5 - - - - - -
Q4275 - Esano aca, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2707.297 - - - - - -
Q4276 - Orion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 271.779 - - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 210.553 - - - - - -
Q4279 - Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2122.721 - - - - - -
Q4280 - Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2355.854 - - - - - -
Q4281 - Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 411.156 - - - - - -
Q4282 - Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 336.608 - - - - - -
Q4283 - Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 455.736 - - - - - -
* Effective October 1, 2025 - December 31, 2025

Drugs not otherwise classified - October 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2025 - December 31, 2025

Drug name Dosage Payment limit Notes
Vasopressin (Long Grove) 1 UNIT 2.462

ASP (Average Sale Price) Drug Pricing History