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 29 * 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
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 309.578 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 94.918 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 171.45 - - - - - -
Q4164 - Helicoll, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1571.962 - - - - - -
Q4166 - Cytal, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 19.205 - - - - - -
Q4168 - Amnioband, 1 mg 1 MG 17.052 - - - - - -
Q4170 - Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 56.733 - - - - - -
Q4171 - Interfyl, 1 mg 1 MG 11.527 - - - - - -
Q4173 - Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 394.057 - - - - - -
Q4175 - Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 65.511 - - - - - -
Q4178 - Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 74.47 - - - - - -
Q4180 - Revita, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 372.656 - - - - - -
Q4184 - Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 624.34 - - - - - -
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 153.452 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 248.371 - - - - - -
Q4188 - Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 637.632 - - - - - -
Q4190 - Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 320.381 - - - - - -
Q4191 - Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1537 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 104.163 - - - - - -
Q4197 - Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 121.626 - - - - - -
Q4199 - Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 317.637 - - - - - -
Q4203 - Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 300.181 - - - - - -
Q4205 - Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1248.213 - - - - - -
Q4210 - Axolotl graft or axolotl dualgraft, per square centimeter 1 SQ CM 848 - - - - - -
Q4217 - Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 525.18 - - - - - -
* 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