ASP Drug Pricing - (2nd Quarter)
April 2022
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2021 (4th 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 24 * Effective April 1, 2022 through June 30, 2022
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 131.042 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 111.056 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 131.838 - - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 534.888 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 91.191 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 148.551 - - - - - -
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 155.235 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 232.608 - - - - - -
Q4195 - Puraply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 73.247 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 108.332 - - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.276 - - - - - -
Q5103 - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 10 MG 38.682 - - - - - -
Q5104 - Injection, infliximab-abda, biosimilar, (renflexis), 10 mg 10 MG 61.095 - - - - - -
Q5105 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units 100 UNITS 0.826 - - - - - -
Q5106 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units 1000 UNITS 8.256 - - - - - -
Q5107 - Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg 10 MG 36.131 - - - - - -
Q5108 - Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg 0.5 MG 179.848 - - - - - -
Q5110 - Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram 1 MCG 0.356 - - - - - -
Q5111 - Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg 0.5 MG 183.412 - - - - - -
Q5112 - Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg 10 MG 76.886 - - - - - -
Q5113 - Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg 10 MG 52.588 - - - - - -
Q5114 - Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg 10 MG 50.111 - - - - - -
Q5115 - Injection, rituximab-abbs, biosimilar, (truxima), 10 mg 10 MG 53.691 - - - - - -
Q5116 - Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg 10 MG 51.016 - - - - - -
Q5117 - Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg 10 MG 42.882 - - - - - -
* Effective April 1, 2022 through June 30, 2022

Drugs not otherwise classified - April 2022

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2022 through June 30, 2022

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.996
Allopurinol Sodium 500 MG 2676.366
Aminocaproic acid 250 MG 0.292
Aztreonam 500 MG 13.886
Bumetanide 0.25 MG 0.331
Bupivacaine 1 ML 0.101
Clindamycin Phosphate 150 MG 0.966
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.782 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.282
Doxycycline Hyclate 100 MG 16.75
Esmolol Hydrochloride 10 MG 0.321
Famotidine 10 MG 0.372
Flumazenil 0.1 MG 0.794
Folic Acid 5 MG 2.975
Glucarpidase 10 UNITS 362.572
Glycopyrrolate injection 0.2 MG 1.999
Immune Globulin (Cutaquig) 100 MG 12.768
Immune Globulin (Panzyga) 500 MG 75.135
Labetalol Hcl 5 MG 0.204
Metoprolol Tartrate 1 MG 0.128
Metronidazole inj 500 MG 1.145
Nitroglycerin 5 MG 1.292
Olanzapine short acting intramuscular injection 0.5 MG 0.89
Paliperidone Palmitate (Invega Trinza) 1 MG 10.688
Rifampin 600 MG 88.89
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.447
Sulfamethoxazole-Trimethoprim 400-80 MG 0.642
Vasopressin 20 UNITS 219.462

ASP (Average Sale Price) Drug Pricing History