ASP Drug Pricing - (3rd Quarter)
July 2023
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2023 (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 28 * Effective Jul 1, 2023 through Sep 30, 2023
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 31.213 20% - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 285.745 20% - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 137.374 20% - - - - -
Q4134 - Hmatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 162.078 20% - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 104.346 20% - - - - -
Q4143 - Repriza, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 27.823 20% - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 77.145 20% - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 136.184 20% - - - - -
Q4152 - Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 50.179 20% - - - - -
Q4153 - Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 133.825 20% - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 130.411 20% - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 420.539 20% - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 92.907 20% - - - - -
Q4161 - Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 134.825 20% - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 165.168 20% - - - - -
Q4166 - Cytal, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 18.9 20% - - - - -
Q4168 - Amnioband, 1 mg 1 MG 17.486 20% - - - - -
Q4169 - Artacent wound, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 264.413 20% - - - - -
Q4170 - Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 42.753 20% - - - - -
Q4171 - Interfyl, 1 mg 1 MG 12.991 20% - - - - -
Q4173 - Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 367.452 20% - - - - -
Q4175 - Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 63.48 20% - - - - -
Q4176 - Neopatch or therion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 65.919 20% - - - - -
Q4178 - Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 89.468 20% - - - - -
Q4180 - Revita, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 103.693 20% - - - - -
* Effective Jul 1, 2023 through Sep 30, 2023

Drugs not otherwise classified - July 2023

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective Jul 1, 2023 through Sep 30, 2023

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.305
Aztreonam 500 MG 14.775
Bumetanide 0.25 MG 0.383
Carmustine (Accord) 100 MG 654.42
Diltiazem Hydrochloride 5 MG 0.342
Doxycycline Hyclate 100 MG 16.063
Famotidine 10 MG 0.417
Flumazenil 0.1 MG 0.812
Folic Acid 5 MG 2.586
Furosemide (Phlow Corporation) 20 MG 1.579
Glucarpidase 10 UNITS 380.699
Glycopyrrolate injection 0.2 MG 1.348 providers must check the crosswalk file to determine the correct payment allowance
Glycopyrrolate injection (Fresenius Kabi) 0.2 MG 4.852 providers must check the crosswalk file to determine the correct payment allowance
Metoprolol Tartrate 1 MG 0.151
Olanzapine short acting intramuscular injection 0.5 MG 0.9
Rifampin 600 MG 111.851
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.763
Sulfamethoxazole-Trimethoprim 400-80 MG 0.892

ASP (Average Sale Price) Drug Pricing History