ASP Drug Pricing - (4th Quarter)
October 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2023 (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 29 * Effective October 1, 2023 - December 31, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4190 - Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 433.016 20% - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 103.471 20% - - - - -
Q4197 - Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 148.072 20% - - - - -
Q4199 - Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 352.248 20% - - - - -
Q4201 - Matrion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 121.388 20% - - - - -
Q4203 - Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 289.409 20% - - - - -
Q4205 - Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1484 20% - - - - -
Q4210 - Axolotl graft or axolotl dualgraft, per square centimeter 1 SQ CM 848 20% - - - - -
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 784.23 20% - - - - -
Q4222 - Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 102.034 20% - - - - -
Q4225 - Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 32.071 20% - - - - -
Q4226 - Myown skin, includes harvesting and preparation procedures, per square centimeter 1 SQ CM 246.969 20% - - - - -
Q4227 - Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 147.21 20% - - - - -
Q4229 - Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 162.008 20% - - - - -
Q4232 - Corplex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 148.99 20% - - - - -
Q4234 - Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 513.177 20% - - - - -
Q4235 - Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 148.456 20% - - - - -
Q4236 - Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1111.365 20% - - - - -
Q4246 - Coretext or protext, per cc 1 CC 2968 20% - - - - -
Q4247 - Amniotext patch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 530 20% - - - - -
Q4248 - Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1049.398 20% - - - - -
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 121.707 20% - - - - -
Q4253 - Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 425.615 20% - - - - -
Q4258 - Enverse, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 69.617 20% - - - - -
Q4259 - Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 997.699 20% - - - - -
* Effective October 1, 2023 - December 31, 2023

Drugs not otherwise classified - October 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2023 - December 31, 2023

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.287
Aztreonam 500 MG 14.712
Bumetanide 0.25 MG 0.391
Carmustine (Accord) 100 MG 594.083
Diltiazem Hydrochloride 5 MG 0.342
Doxycycline Hyclate 100 MG 15.616
Famotidine 10 MG 0.408
Flumazenil 0.1 MG 0.795
Folic Acid 5 MG 2.905
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.345 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 4.884 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.14171822859631
Rifampin 600 MG 84.394
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.692
Sulfamethoxazole-Trimethoprim 400-80 MG 0.636

ASP (Average Sale Price) Drug Pricing History