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 37 * 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
Q4323 - Alloply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1563.145 - - - - - -
Q4325 - Acapatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1707.805 - - - - - -
Q4326 - Woundplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1062.719 - - - - - -
Q4328 - Most, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3440.627 - - - - - -
Q4331 - Axolotl graft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1589.715 - - - - - -
Q4332 - Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1681.333 - - - - - -
Q4339 - Artacent vericlen, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2055.34 - - - - - -
Q4340 - Simpligraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1377.894 - - - - - -
Q4341 - Simplimax, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3524.112 - - - - - -
Q4342 - Theramend, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2271.193 - - - - - -
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 3574.386 - - - - - -
Q4345 - Matrix hd allograft dermis, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2650 - - - - - -
Q4346 - Shelter dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3663.787 - - - - - -
Q4347 - Rampart dl matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3099.433 - - - - - -
Q4348 - Sentry sl matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2034.877 - - - - - -
Q4350 - Palisade dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3608.093 - - - - - -
Q4353 - Xceed tl matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 4148.84 - - - - - -
Q4355 - Abiomend xplus membrane and abiomend xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2835.716 - - - - - -
Q4357 - Xwrap plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 4770 - - - - - -
Q4358 - Xwrap dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 5893.344 - - - - - -
Q4359 - Choriply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2779.32 - - - - - -
Q4361 - Epixpress, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2120 - - - - - -
Q4367 - Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 752.393 - - - - - -
Q5099 - Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg 1 MG 12.642 - - - - - -
* 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