ASP Drug Pricing - (1st Quarter)
January 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2023 (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 28 * Effective January 1, 2024 through March 31, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4106 - Dermagraft, per square centimeter 1 SQ CM 44.944 - - - - - -
Q4108 - Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 44.36 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 39.055 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.437 - - - - - -
Q4114 - Integra flowable wound matrix, injectable, 1 cc 1 CC 1507 - - - - - -
Q4115 - Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.13 - - - - - -
Q4117 - Hyalomatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 16.913 - - - - - -
Q4118 - Matristem micromatrix, 1 mg 1 MG 2.548 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 45 - - - - - -
Q4123 - Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 37.602 - - - - - -
Q4124 - Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 9.284 - - - - - -
Q4126 - Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 78.343 - - - - - -
Q4127 - Talymed, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 68.487 - - - - - -
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.732 - - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 158.237 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 136.324 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 113.678 - - - - - -
Q4141 - Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 39.449 - - - - - -
Q4143 - Repriza, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 29.68 - - - - - -
Q4147 - Architect, architect px, or architect fx, extracellular matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 147.222222222222 - - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 77.655 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 132.875 - - - - - -
Q4152 - Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 50.416 - - - - - -
Q4153 - Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 116.257 - - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 148.462 - - - - - -
* Effective January 1, 2024 through March 31, 2024

Drugs not otherwise classified - January 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2024 through March 31, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.29
Aztreonam 500 MG 14.778
Diltiazem Hydrochloride 5 MG 0.372
Doxycycline Hyclate 100 MG 15.942
Famotidine 10 MG 0.412
Flumazenil 0.1 MG 0.799
Folic Acid 5 MG 2.873
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Glycopyrrolate injection (Fresenius Kabi) 0.1 MG 2.698 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.144
Rifampin 600 MG 58.761
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.393
Sulfamethoxazole-Trimethoprim 400-80 MG 0.744

ASP (Average Sale Price) Drug Pricing History