ASP Drug Pricing - (3rd Quarter)
July 2022
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2022 (1st 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 Jul 1, 2022 through Sep 30, 2022
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q0167 - Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 2.5 MG 0.877 - - - - - -
Q2043 - Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion Per infusion (minimum 50 million cells) 55114.745 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 129.993 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 56.067 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 139.476 - - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.822 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.365 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 11.624 - - - - - -
Q4106 - Dermagraft, per square centimeter 1 SQ CM 26.763 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 41.798 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.194 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 43.218 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 135.467 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 98.483 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 134.793 - - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 535.093 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 92.336 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 90.42 - - - - - -
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 156.222 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 237.064 - - - - - -
Q4195 - Puraply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 71.232 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 109.45 - - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.231 - - - - - -
Q5103 - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 10 MG 33.257 - - - - - -
Q5104 - Injection, infliximab-abda, biosimilar, (renflexis), 10 mg 10 MG 51.253 - - - - - -
* Effective Jul 1, 2022 through Sep 30, 2022

Drugs not otherwise classified - July 2022

 

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

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 0.851
Allopurinol Sodium 500 MG 2741.738
Aminocaproic acid 250 MG 0.314
Aztreonam 500 MG 13.988
Bortezomib (Dr. Reddy's) 0.1 MG 23.125 Added July 2022
Bumetanide 0.25 MG 0.307
Bupivacaine 1 ML 0.113
Clindamycin Phosphate 150 MG 0.954
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.746 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.295
Doxycycline Hyclate 100 MG 16.117
Esmolol Hydrochloride 10 MG 0.297
Famotidine 10 MG 0.329
Flumazenil 0.1 MG 0.885
Folic Acid 5 MG 3.029
Glucarpidase 10 UNITS 362.572
Glycopyrrolate injection 0.2 MG 1.585
Immune Globulin (Panzyga) 500 MG 69.35
Labetalol Hcl 5 MG 0.13
Metoprolol Tartrate 1 MG 0.146
Metronidazole inj 500 MG 1.425
Nitroglycerin 5 MG 1.29
Olanzapine short acting intramuscular injection 0.5 MG 1.098
Paliperidone Palmitate (Invega Trinza) 1 MG 11.181
Rifampin 600 MG 68.27
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.36
Sulfamethoxazole-Trimethoprim 400-80 MG 0.677
Vasopressin 20 UNITS 189.538

ASP (Average Sale Price) Drug Pricing History