ASP Drug Pricing - (3rd Quarter)
July 2021
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2021 (1st 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 23 * Effective Jul 1, 2021 through Sep 30, 2021
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
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 0.953 - - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.953 - - - - - -
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 0.016 - - - - - -
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 - - - - - -
Q0166 - Granisetron hydrochloride, 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 24 hour dosage regimen 1 MG 1.463 - - - - - -
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 0.508 - - - - - -
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) 51712.975 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 257.087 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 55.519 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 140.373 - - - - - -
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 30.43 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 10.038 - - - - - -
Q4106 - Dermagraft, per square centimeter 1 SQ CM 31.97 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 41.352 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 6.962 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 43.439 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 136.457 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 87.748 - - - - - -
Q4145 - Epifix, injectable, 1 mg 1 MG 18.619 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 127.13 - - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 109.069 - - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 583.667 - - - - - -
* Effective Jul 1, 2021 through Sep 30, 2021

Drugs not otherwise classified - July 2021

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective Jul 1, 2021 through Sep 30, 2021

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.932
Allopurinol Sodium 500 MG 3320.364
Aminocaproic acid 250 MG 0.293
Aztreonam 500 MG 14.167
Bumetanide 0.25 MG 0.281
Bupivacaine 1 ML 0.089
Clindamycin Phosphate 150 MG 0.824
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 2.21 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.294
Doxycycline Hyclate 100 MG 19.079
Esmolol Hydrochloride 10 MG 0.312
Famotidine 10 MG 0.432
Flumazenil 0.1 MG 0.793
Folic Acid 5 MG 2.919
Glucarpidase 10 UNITS 345.308
Glycopyrrolate injection 0.2 MG 2.317
Immune Globulin (Cutaquig) 100 MG 13.394
Immune Globulin (Panzyga) 500 MG 62.968
Labetalol Hcl 5 MG 0.126
Metoprolol Tartrate 1 MG 0.141
Metronidazole inj 500 MG 1.138
Nitroglycerin 5 MG 1.28
Olanzapine short acting intramuscular injection 0.5 MG 1.282
Paliperidone Palmitate (Invega Trinza) 1 MG 10.524
Rabies Immune Globulin (Kedrab) 150 IU 243.784
Rifampin 600 MG 106.951
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.481
Sulfamethoxazole-Trimethoprim 400-80 MG 0.581
Vasopressin 20 UNITS 210.415

ASP (Average Sale Price) Drug Pricing History