ASP Drug Pricing - (2nd Quarter)
April 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2022 (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 26 * Effective April 1, 2023 through June 30, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 53.078 20% - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 139.774 20% - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.793 20% - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.43 20% - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.709 20% - - - - -
Q4103 - Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.939 20% - - - - -
Q4104 - Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 47.629 20% - - - - -
Q4105 - Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 23.847 20% - - - - -
Q4108 - Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 42.021 20% - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 40.699 20% - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.321 20% - - - - -
Q4114 - Integra flowable wound matrix, injectable, 1 cc 1 CC 1520.127 20% - - - - -
Q4115 - Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 16.366 20% - - - - -
Q4117 - Hyalomatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 11.715 20% - - - - -
Q4118 - Matristem micromatrix, 1 mg 1 MG 2.493 20% - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 45.955 20% - - - - -
Q4123 - Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 22.25 20% - - - - -
Q4124 - Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 10.139 20% - - - - -
Q4126 - Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 86.316 20% - - - - -
Q4127 - Talymed, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 89.391 20% - - - - -
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 31.212 20% - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 339.191 20% - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 132.786 20% - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 95.407 20% - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 80.186 20% - - - - -
* Effective April 1, 2023 through June 30, 2023

Drugs not otherwise classified - April 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2023 through June 30, 2023

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.235
Allopurinol Sodium 500 MG 2979.421
Aminocaproic acid 250 MG 0.285
Aztreonam 500 MG 14.91
Bumetanide 0.25 MG 0.354
Bupivacaine 1 ML 0.143
Carmustine (Accord) 100 MG 723.117 Added April 2023
Clindamycin Phosphate 150 MG 0.997
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.779 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.327
Doxycycline Hyclate 100 MG 16.652
Esmolol Hydrochloride 10 MG 0.278
Famotidine 10 MG 0.405
Flumazenil 0.1 MG 0.969
Folic Acid 5 MG 2.525
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.28 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 5.048 Added April 2023 - providers must check the crosswalk file to determine the correct payment allowance
Immune Globulin (Panzyga) 500 MG 65.821
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 UNITS 7.19
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 UNITS 15.735
Labetalol Hcl 5 MG 0.272
Metoprolol Tartrate 1 MG 0.146
Metronidazole inj 500 MG 1.327
Nitroglycerin 5 MG 1.387
Olanzapine short acting intramuscular injection 0.5 MG 0.998
Paliperidone Palmitate (Invega Trinza) 1 MG 11.657
Rifampin 600 MG 102.954
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.746
Sulfamethoxazole-Trimethoprim 400-80 MG 0.746
Vasopressin 20 UNITS 101.775
Vasopressin (American Regent) 20 UNITS 86.938

ASP (Average Sale Price) Drug Pricing History