ASP Drug Pricing - (3rd Quarter)
July 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2024 (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 30 * Effective Jul 1, 2024 through Sep 30, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4178 - Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 83.494 - - - - - -
Q4180 - Revita, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 393.375 - - - - - -
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 154.668 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 244.487 - - - - - -
Q4188 - Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 543.202 - - - - - -
Q4190 - Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 314.303 - - - - - -
Q4191 - Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1454.877 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 103.745 - - - - - -
Q4197 - Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 94.441 - - - - - -
Q4199 - Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 273.203 - - - - - -
Q4201 - Matrion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 93.245 - - - - - -
Q4205 - Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1309.047 - - - - - -
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 573.002 - - - - - -
Q4221 - Amniowrap2, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1855 - - - - - -
Q4222 - Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 108.67 - - - - - -
Q4227 - Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1038.8 - - - - - -
Q4229 - Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 896.429 - - - - - -
Q4232 - Corplex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 233.751 - - - - - -
Q4234 - Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 457.844 - - - - - -
Q4235 - Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 149.969 - - - - - -
Q4236 - Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 811.505 - - - - - -
Q4238 - Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 883.616 - - - - - -
Q4239 - Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2385 - - - - - -
Q4248 - Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1106.816 - - - - - -
* Effective Jul 1, 2024 through Sep 30, 2024

Drugs not otherwise classified - July 2024

 

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

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.303
Aztreonam 500 MG 2.128
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.308 Added July 2024
Diltiazem Hydrochloride 5 MG 0.374
Doxycycline Hyclate 100 MG 13.505
Famotidine 10 MG 0.3
Flumazenil 0.1 MG 1.123
Folic Acid 5 MG 2.808
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Glycopyrrolate injection (Fresenius Kabi) 0.1 MG 2.698 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.136
Rifampin 600 MG 49.595
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.432
Sulfamethoxazole-Trimethoprim 400-80 MG 0.572

ASP (Average Sale Price) Drug Pricing History