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 31 * 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
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 285.955 - - - - - -
Q4253 - Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 253.517 - - - - - -
Q4256 - Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1067.48 - - - - - -
Q4257 - Relese, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 528.005 - - - - - -
Q4258 - Enverse, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 76.466 - - - - - -
Q4259 - Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1334.353 - - - - - -
Q4262 - Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 706.77 - - - - - -
Q4263 - Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 529.163 - - - - - -
Q4265 - Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2114.7 - - - - - -
Q4266 - Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1584.7 - - - - - -
Q4267 - Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 729.254 - - - - - -
Q4268 - Surgraft ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1209.664 - - - - - -
Q4271 - Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1749 - - - - - -
Q4276 - Orion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 908.481 - - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 404.713 - - - - - -
Q4280 - Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1590 - - - - - -
Q4281 - Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1270.399 - - - - - -
Q4282 - Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 669.82 - - - - - -
Q4283 - Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1059.209 - - - - - -
Q4294 - Amnio quad-core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2279 - - - - - -
Q4295 - Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2067 - - - - - -
Q4298 - Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2173 - - - - - -
Q4299 - Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2385 - - - - - -
Q4304 - Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1189.21 - - - - - -
Q4332 - Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1718.585 - - - - - -
* 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