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 31 * 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
Q4225 - Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1537 - - - - - -
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 936.442 - - - - - -
Q4232 - Corplex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 251.851 - - - - - -
Q4234 - Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 546.813 - - - - - -
Q4235 - Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 136.359 - - - - - -
Q4236 - Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 484.407 - - - - - -
Q4238 - Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 929.207 - - - - - -
Q4239 - Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2464.699 - - - - - -
Q4248 - Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1107.7 - - - - - -
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 86.02 - - - - - -
Q4253 - Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 144.956 - - - - - -
Q4256 - Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 966.161 - - - - - -
Q4257 - Relese, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 561.883 - - - - - -
Q4258 - Enverse, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 67.672 - - - - - -
Q4259 - Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1290.099 - - - - - -
Q4262 - Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 314.039 - - - - - -
Q4263 - Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 531.779 - - - - - -
Q4265 - Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2114.7 - - - - - -
Q4266 - Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1542.651 - - - - - -
Q4267 - Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 380.426 - - - - - -
Q4268 - Surgraft ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 919.14 - - - - - -
Q4271 - Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1591.4 - - - - - -
Q4276 - Orion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 884.673 - - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 312.786 - - - - - -
* 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