ASP Drug Pricing - (3rd Quarter)
July 2024
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2024 (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, 2024 through Sep 30, 2024
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q2041 - Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION CAR T CELLS 489136.91 - - - - - -
Q2042 - Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose up to 600 million CAR-positive viable T cells 523452.561 - - - - - -
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) 55512.784 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 136.226 - - - - - -
Q2053 - Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR POSITIVE VIABLE T CEL 449440 - - - - - -
Q2054 - Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose Up to 110 million CAR-positive viable T cells, per therapeutic d 496390.205 - - - - - -
Q2055 - Idecabtagene vicleucel, up to 510 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose UP TO 510 MILLION AUTOLOGOUS ANTI-BCMA CAR-POSITIVE VIABLE T CEL 503454.525 - - - - - -
Q2056 - Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose up to 100 million autologous b-cell maturation antigen (bcma) di 507687 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 57.119 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 147.166 - - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.813 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.633 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 11.791 - - - - - -
Q4103 - Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.363 - - - - - -
Q4104 - Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 49.526 - - - - - -
Q4105 - Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 25.17 - - - - - -
Q4108 - Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 51.924 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 44.157 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.142 - - - - - -
Q4114 - Integra flowable wound matrix, injectable, 1 cc 1 CC 1549.363 - - - - - -
Q4115 - Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 15.544 - - - - - -
Q4118 - Matristem micromatrix, 1 mg 1 MG 2.558 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 46.292 - - - - - -
Q4124 - Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.835 - - - - - -
Q4126 - Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 80.922 - - - - - -
* Effective Jul 1, 2024 through Sep 30, 2024

Drugs not otherwise classified - July 2024

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective Jul 1, 2024 through Sep 30, 2024

Drug name Dosage Payment limit Notes
Aminocaproic acid 250 MG 0.303
Aztreonam 500 MG 2.128
Benzylpenicillin Benzathine (Extencilline) 100,000 UNITS 16.308 Added July 2024
Diltiazem Hydrochloride 5 MG 0.374
Doxycycline Hyclate 100 MG 13.505
Famotidine 10 MG 0.3
Flumazenil 0.1 MG 1.123
Folic Acid 5 MG 2.808
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 0.136
Rifampin 600 MG 49.595
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.432
Sulfamethoxazole-Trimethoprim 400-80 MG 0.572

ASP (Average Sale Price) Drug Pricing History