ASP Drug Pricing - (1st Quarter)
January 2021
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2020 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 23 * Effective January 1, 2021 through March 31, 2021
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q0164 - Prochlorperazine maleate, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 5 MG 0.296 - - - - - -
Q0166 - Granisetron hydrochloride, 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen 1 MG 1.463 - - - - - -
Q0167 - Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 2.5 MG 0.803 - - - - - -
Q2043 - Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion Per infusion (minimum 50 million cells) 49649.408 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 298.802 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 54.417 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 140.088 - - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.882 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.456 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 9.563 - - - - - -
Q4106 - Dermagraft, per square centimeter 1 SQ CM 31.858 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 42.33 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.02 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 43.449 - - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 116.594 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 135.234 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 86.589 - - - - - -
Q4145 - Epifix, injectable, 1 mg 1 MG 18.662 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 126.011 - - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 110.822 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 99.526 - - - - - -
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 156.229 - - - - - -
Q4195 - Puraply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 95.485 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 108.758 - - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.413 - - - - - -
* Effective January 1, 2021 through March 31, 2021

Drugs not otherwise classified - January 2021

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2021 through March 31, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.917
Allopurinol Sodium 500 MG 3149.724
Aminocaproic acid 250 MG 0.341
Aztreonam 500 MG 12.574
Bumetanide 0.25 MG 0.354
Bupivacaine 1 ML 0.064
Clindamycin Phosphate 150 MG 0.89
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.737 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.331
Doxycycline Hyclate 100 MG 18.736
Esmolol Hydrochloride 10 MG 0.33
Famotidine 10 MG 0.389
Flumazenil 0.1 MG 0.683
Folic Acid 5 MG 2.638
Glucarpidase 10 UNITS 328.863
Glycopyrrolate injection 0.2 MG 2.399
Immune Globulin (Asceniv) 500 MG 481.77
Immune Globulin (Cutaquig) 100 MG 18.184
Immune Globulin (Panzyga) 500 MG 64.513
Labetalol Hcl 5 MG 0.151
Metoprolol Tartrate 1 MG 0.123
Metronidazole inj 500 MG 1.221
Nitroglycerin 5 MG 1.255
Olanzapine short acting intramuscular injection 0.5 MG 1.263
Paliperidone Palmitate (Invega Trinza) 1 MG 10.195
Rabies Immune Globulin (Kedrab) 150 IU 231.649
Rifampin 600 MG 104.387
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.464
Sulfamethoxazole-Trimethoprim 400-80 MG 0.627
Vasopressin 20 UNITS 203.34

ASP (Average Sale Price) Drug Pricing History