ASP Drug Pricing - (4th Quarter)
October 2022
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2022 (2nd 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 24 * Effective October 1, 2022 - December 31, 2022
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
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 0.533 - - - - - -
Q0139 - Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1 MG 0.533 - - - - - -
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 0.014 - - - - - -
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 0.839 - - - - - -
Q0222 - Injection, bebtelovimab, 175 mg 175 MG 2394 - - - - - -
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) 53505.534 - - - - - -
Q2050 - Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 10 MG 111.985 - - - - - -
Q3027 - Injection, interferon beta-1a, 1 mcg for intramuscular use 1 MCG 54.833 - - - - - -
Q4074 - Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms UP TO 20 MCG 139.224 - - - - - -
Q4081 - Injection, epoetin alfa, 100 units (for esrd on dialysis) 100 UNITS 0.837 - - - - - -
Q4101 - Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.514 - - - - - -
Q4102 - Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.03 - - - - - -
Q4106 - Dermagraft, per square centimeter 1 SQ CM 25.538 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 42.41 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.207 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 44.541 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 135.42 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 97.365 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 133.666 - - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 470.927 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 93.83 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 97.365 - - - - - -
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 156.17 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 235.879 - - - - - -
* Effective October 1, 2022 - December 31, 2022

Drugs not otherwise classified - October 2022

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2022 - December 31, 2022

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 2.162
Allopurinol Sodium 500 MG 2889.811
Aminocaproic acid 250 MG 0.329
Aztreonam 500 MG 14.801
Bortezomib (Dr. Reddy's) 0.1 MG 17.974
Bumetanide 0.25 MG 0.35
Bupivacaine 1 ML 0.123
Clindamycin Phosphate 150 MG 1.018
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.826 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.307
Doxycycline Hyclate 100 MG 17.103
Esmolol Hydrochloride 10 MG 0.299
Famotidine 10 MG 0.346
Flumazenil 0.1 MG 0.938
Folic Acid 5 MG 3.289
Glucarpidase 10 UNITS 362.572
Glycopyrrolate injection 0.2 MG 1.982
Immune Globulin (Panzyga) 500 MG 69.638
Insulin aspart (Fiasp) administration through dme (i.e., insulin pump) 50 Units 8.461 Added October 2022
Insulin lispro-aabc (Lyumjev) administration through dme (i.e., insulin pump) 50 Units 15.871 Added October 2022
Labetalol Hcl 5 MG 0.186
Metoprolol Tartrate 1 MG 0.152
Metronidazole inj 500 MG 1.401
Nitroglycerin 5 MG 1.362
Olanzapine short acting intramuscular injection 0.5 MG 1.042
Paliperidone Palmitate (Invega Trinza) 1 MG 11.288
Rifampin 600 MG 95.198
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.373
Sulfamethoxazole-Trimethoprim 400-80 MG 0.669
Vasopressin 20 UNITS 172.139
Vasopressin (American Regent) 20 UNITS 136.351 Added October 2022

ASP (Average Sale Price) Drug Pricing History