ASP Drug Pricing - (1st Quarter)
January 2022
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2021 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 23 * Effective January 1, 2022 through March 31, 2022
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J9400 - Injection, ziv-aflibercept, 1 mg 1 MG 7.661 - - - - - -
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 1.093 - - - - - -
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 0.256 - - - - - -
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 0.589 - - - - - -
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) 52421.579 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 200.515 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 54.838 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 140.409 - - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.822 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.442 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 9.8 - - - - - -
Q4106 - Dermagraft, per square centimeter 1 SQ CM 31.971 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 42.702 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 6.987 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 43.823 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 134.055 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 101.037 - - - - - -
Q4145 - Epifix, injectable, 1 mg 1 MG 19.478 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 127.551 - - - - - -
* Effective January 1, 2022 through March 31, 2022

Drugs not otherwise classified - January 2022

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2022 through March 31, 2022

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.973
Allopurinol Sodium 500 MG 3175.581
Aminocaproic acid 250 MG 0.303
Aztreonam 500 MG 14.07
Bumetanide 0.25 MG 0.289
Bupivacaine 1 ML 0.107
Clindamycin Phosphate 150 MG 1.054
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.274 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.287
Doxycycline Hyclate 100 MG 17.547
Esmolol Hydrochloride 10 MG 0.292
Famotidine 10 MG 0.434
Flumazenil 0.1 MG 0.894
Folic Acid 5 MG 2.522
Glucarpidase 10 UNITS 345.308
Glycopyrrolate injection 0.2 MG 2.072
Immune Globulin (Cutaquig) 100 MG 13.526
Immune Globulin (Panzyga) 500 MG 65.046
Labetalol Hcl 5 MG 0.16
Metoprolol Tartrate 1 MG 0.14
Metronidazole inj 500 MG 1.177
Nitroglycerin 5 MG 1.352
Olanzapine short acting intramuscular injection 0.5 MG 1.122
Paliperidone Palmitate (Invega Trinza) 1 MG 10.673
Rifampin 600 MG 98.068
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.497
Sulfamethoxazole-Trimethoprim 400-80 MG 0.603
Vasopressin 20 UNITS 219.428

ASP (Average Sale Price) Drug Pricing History