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 32 * 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
Q4279 - Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2385 - - - - - -
Q4280 - Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3180 - - - - - -
Q4281 - Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 829.647 - - - - - -
Q4282 - Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 649.02 - - - - - -
Q4283 - Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 800.004 - - - - - -
Q4290 - Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1961 - - - - - -
Q4293 - Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1584.7 - - - - - -
Q4294 - Amnio quad-core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2279 - - - - - -
Q4295 - Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2067 - - - - - -
Q4296 - Rebound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2279 - - - - - -
Q4297 - Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2279 - - - - - -
Q4299 - Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2491 - - - - - -
Q4300 - Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2114.7 - - - - - -
Q4301 - Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2385 - - - - - -
Q4302 - Complete aca, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2008.7 - - - - - -
Q4303 - Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3460.882 - - - - - -
Q4304 - Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1164.741 - - - - - -
Q4310 - Procenta, per 100 mg 100 MG 2438.326 - - - - - -
Q4332 - Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1722.5 - - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.362 - - - - - -
Q5103 - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 10 MG 13.618 - - - - - -
Q5104 - Injection, infliximab-abda, biosimilar, (renflexis), 10 mg 10 MG 27.182 - - - - - -
Q5105 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units 100 UNITS 0.762 - - - - - -
Q5106 - Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units 1000 UNITS 7.618 - - - - - -
Q5107 - Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg 10 MG 26.585 - - - - - -
* 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