ASP Drug Pricing - (1st Quarter)
January 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2022 (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 27 * Effective January 1, 2023 through March 31, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 104.782 - - - - - -
Q4170 - Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 81.108 - - - - - -
Q4171 - Interfyl, 1 mg 1 MG 49.232 - - - - - -
Q4175 - Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 63.377 - - - - - -
Q4176 - Neopatch or therion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 129.619 - - - - - -
Q4180 - Revita, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 166.129 - - - - - -
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 153.459 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 241.746 - - - - - -
Q4195 - Puraply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 71.232 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 109.761 - - - - - -
Q4197 - Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 178.341 - - - - - -
Q4199 - Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 317.245 - - - - - -
Q4201 - Matrion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 170.263 - - - - - -
Q4203 - Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 222.391 - - - - - -
Q4210 - Axolotl graft or axolotl dualgraft, per square centimeter 1 SQ CM 848 - - - - - -
Q4227 - Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 288.289 - - - - - -
Q4231 - Corplex p, per cc 1 CC 677.326 - - - - - -
Q4232 - Corplex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 297.397 - - - - - -
Q4235 - Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 150.549 - - - - - -
Q4244 - Procenta, per 200 mg 200 MG 10480.263 - - - - - -
Q4246 - Coretext or protext, per cc 1 CC 2968 - - - - - -
Q4247 - Amniotext patch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 530 - - - - - -
Q4248 - Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 133.973 - - - - - -
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 175.723 - - - - - -
Q4254 - Novafix dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 355.876 - - - - - -
* Effective January 1, 2023 through March 31, 2023

Drugs not otherwise classified - January 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2023 through March 31, 2023

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.009
Allopurinol Sodium 500 MG 2890.625
Aminocaproic acid 250 MG 0.311
Aztreonam 500 MG 14.697
Bumetanide 0.25 MG 0.439
Bupivacaine 1 ML 0.158
Clindamycin Phosphate 150 MG 1.088
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.764 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.357
Doxycycline Hyclate 100 MG 17.545
Esmolol Hydrochloride 10 MG 0.283
Famotidine 10 MG 0.365
Flumazenil 0.1 MG 0.913
Folic Acid 5 MG 3.186
Furosemide (Phlow Corporation) 20 MG 1.579 Added January 2023
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.455
Immune Globulin (Panzyga) 500 MG 71.583
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 UNITS 7.694
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 UNITS 15.745
Labetalol Hcl 5 MG 0.189
Metoprolol Tartrate 1 MG 0.146
Metronidazole inj 500 MG 1.345
Nitroglycerin 5 MG 1.349
Olanzapine short acting intramuscular injection 0.5 MG 1.079
Paliperidone Palmitate (Invega Trinza) 1 MG 11.379
Premetrexed (Sandoz) 10 MG 13.639 Added January 2023
Rifampin 600 MG 99.719
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.814
Sulfamethoxazole-Trimethoprim 400-80 MG 0.606
Vasopressin 20 UNITS 141.221
Vasopressin (American Regent) 20 UNITS 104.855

ASP (Average Sale Price) Drug Pricing History