ASP Drug Pricing - (2nd Quarter)
April 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Oct 2023 (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 28 * Effective April 1, 2024 through June 30, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.827 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.62 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.417 - - - - - -
Q4103 - Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.561 - - - - - -
Q4104 - Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 48.875 - - - - - -
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 24.599 - - - - - -
Q4108 - Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 49.681 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.216 - - - - - -
Q4114 - Integra flowable wound matrix, injectable, 1 cc 1 CC 1497.923 - - - - - -
Q4118 - Matristem micromatrix, 1 mg 1 MG 2.561 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 46.134 - - - - - -
Q4124 - Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 8.968 - - - - - -
Q4126 - Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 89.11 - - - - - -
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.689 - - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 110.441 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 143.226 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 104.907 - - - - - -
Q4141 - Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 41.351 - - - - - -
Q4143 - Repriza, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 29.149 - - - - - -
Q4147 - Architect, architect px, or architect fx, extracellular matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 147.222 - - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 78.273 - - - - - -
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 44.903 - - - - - -
Q4153 - Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 125.556 - - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 155.454 - - - - - -
* Effective April 1, 2024 through June 30, 2024

Drugs not otherwise classified - April 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective April 1, 2024 through June 30, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.281
Aztreonam 500 MG 14.544
Diltiazem Hydrochloride 5 MG 0.354
Doxycycline Hyclate 100 MG 16.001
Famotidine 10 MG 0.391
Flumazenil 0.1 MG 1.21
Folic Acid 5 MG 2.833
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Glycopyrrolate injection (Fresenius Kabi) 0.1 MG 1.978 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.138
Rifampin 600 MG 89.91
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.447
Sulfamethoxazole-Trimethoprim 400-80 MG 0.708

ASP (Average Sale Price) Drug Pricing History