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 26 * 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
`Q9966` - Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml	1 ML	0.34	-	-	-	-	-	-
`Q9967` - Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml	1 ML	0.116	-	-	-	-	-	-
`Q9991` - Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg	Less than or equal to 100 MG	1858.61	-	-	-	-	-	-
`Q9992` - Injection, buprenorphine extended-release (sublocade), greater than 100 mg	Greater than 100 MG	1858.61	-	-	-	-	-	-
* 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