ASP Drug Pricing - (1st Quarter)
January 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2023 (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 30 * Effective January 1, 2024 through March 31, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4221 - Amniowrap2, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1696 - - - - - -
Q4222 - Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 91.082 - - - - - -
Q4226 - Myown skin, includes harvesting and preparation procedures, per square centimeter 1 SQ CM 386.492 - - - - - -
Q4227 - Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 96.187 - - - - - -
Q4229 - Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 106.016 - - - - - -
Q4231 - Corplex p, per cc 1 CC 1487.18 - - - - - -
Q4232 - Corplex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 69.615 - - - - - -
Q4234 - Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 628.886 - - - - - -
Q4235 - Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 147.064 - - - - - -
Q4236 - Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 868.138 - - - - - -
Q4238 - Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1590 - - - - - -
Q4239 - Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 68.678 - - - - - -
Q4246 - Coretext or protext, per cc 1 CC 2968 - - - - - -
Q4247 - Amniotext patch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 530 - - - - - -
Q4248 - Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1079.089 - - - - - -
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 295.979 - - - - - -
Q4253 - Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 470.747 - - - - - -
Q4258 - Enverse, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 73.648 - - - - - -
Q4262 - Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1170.957 - - - - - -
Q4263 - Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1054.305 - - - - - -
Q4267 - Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 874.5 - - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 527.995 - - - - - -
Q4282 - Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 903.276 - - - - - -
Q5101 - Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 1 MCG 0.319 - - - - - -
Q5103 - Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 10 MG 14.294 - - - - - -
* Effective January 1, 2024 through March 31, 2024

Drugs not otherwise classified - January 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2024 through March 31, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.29
Aztreonam 500 MG 14.778
Diltiazem Hydrochloride 5 MG 0.372
Doxycycline Hyclate 100 MG 15.942
Famotidine 10 MG 0.412
Flumazenil 0.1 MG 0.799
Folic Acid 5 MG 2.873
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 399.73
Glycopyrrolate injection (Fresenius Kabi) 0.1 MG 2.698 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.144
Rifampin 600 MG 58.761
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.393
Sulfamethoxazole-Trimethoprim 400-80 MG 0.744

ASP (Average Sale Price) Drug Pricing History