ASP Drug Pricing - (4th Quarter)
October 2021
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2021 (2nd 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 23 * Effective October 1, 2021 through December 31, 2021
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
P9041 - Infusion, albumin (human), 5%, 50 ml 50 ML 10.49 - - - - 95% 10.49
P9045 - Infusion, albumin (human), 5%, 250 ml 250 ML 52.45 - - - - 95% 52.45
P9046 - Infusion, albumin (human), 25%, 20 ml 20 ML 20.98 - - - - 95% 20.98
P9047 - Infusion, albumin (human), 25%, 50 ml 50 ML 52.45 - - - - 95% 52.45
Q0138 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) 1 MG 0.997 - - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.997 - - - - - -
Q0162 - Ondansetron 1 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 1 MG 0.015 - - - - - -
Q0164 - Prochlorperazine maleate, 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 5 MG 0.329 - - - - - -
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 0.445 - - - - - -
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) 53017.576 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 234.028 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 55.292 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 140.243 - - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.815 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.427 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 11.047 - - - - - -
Q4106 - Dermagraft, per square centimeter 1 SQ CM 32.026 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 43.431 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.344 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 43.838 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 133.735 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 94.162 - - - - - -
Q4145 - Epifix, injectable, 1 mg 1 MG 17.959 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 124.416 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 96.264 - - - - - -
* Effective October 1, 2021 through December 31, 2021

Drugs not otherwise classified - October 2021

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2021 through December 31, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.118
Allopurinol Sodium 500 MG 3212.092
Aminocaproic acid 250 MG 0.303
Aztreonam 500 MG 14.266
Bumetanide 0.25 MG 0.307
Bupivacaine 1 ML 0.09
Clindamycin Phosphate 150 MG 0.918
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.273 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.278
Doxycycline Hyclate 100 MG 18.396
Esmolol Hydrochloride 10 MG 0.324
Famotidine 10 MG 0.412
Flumazenil 0.1 MG 0.738
Folic Acid 5 MG 3.08
Glucarpidase 10 UNITS 345.308
Glycopyrrolate injection 0.2 MG 2.26
Immune Globulin (Cutaquig) 100 MG 13.324
Immune Globulin (Panzyga) 500 MG 63.582
Labetalol Hcl 5 MG 0.252
Metoprolol Tartrate 1 MG 0.15
Metronidazole inj 500 MG 1.235
Nitroglycerin 5 MG 1.367
Olanzapine short acting intramuscular injection 0.5 MG 1.323
Paliperidone Palmitate (Invega Trinza) 1 MG 10.693
Rifampin 600 MG 103.478
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.501
Sulfamethoxazole-Trimethoprim 400-80 MG 0.619
Vasopressin 20 UNITS 219.196

ASP (Average Sale Price) Drug Pricing History