ASP Drug Pricing - (4th Quarter)
October 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2024 (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, 2024 - December 31, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4115 - Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 13.578 - - - - - -
Q4118 - Matristem micromatrix, 1 mg 1 MG 2.556 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 48.865 - - - - - -
Q4124 - Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 9.162 - - - - - -
Q4126 - Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 87.514 - - - - - -
Q4127 - Talymed, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 79.066 - - - - - -
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.5 - - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 151.128 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 136.96 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 107.604 - - - - - -
Q4143 - Repriza, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 33.92 - - - - - -
Q4147 - Architect, architect px, or architect fx, extracellular matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 147.222 - - - - - -
Q4148 - Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 129.581 - - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 85.862 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 139.99 - - - - - -
Q4152 - Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 46.327 - - - - - -
Q4153 - Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 154.583 - - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 151.131 - - - - - -
Q4155 - Neoxflo or clarixflo, 1 mg 1 MG 26.327 - - - - - -
Q4156 - Neox 100 or clarix 100, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 66.199 - - - - - -
Q4158 - Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 81.46 - - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 263.308 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 96.396 - - - - - -
Q4161 - Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1855.896 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 180.038 - - - - - -
* Effective October 1, 2024 - December 31, 2024

Drugs not otherwise classified - October 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2024 - December 31, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.319
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.783
Diltiazem Hydrochloride 5 MG 0.378
Doxycycline Hyclate 100 MG 12.923
Famotidine 10 MG 0.324
Flumazenil 0.1 MG 1.183
Folic Acid 5 MG 3.17
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Metoprolol Tartrate 1 MG 0.129
Rifampin 600 MG 91.656
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.393
Sulfamethoxazole-Trimethoprim 400-80 MG 0.629

ASP (Average Sale Price) Drug Pricing History