Medicare Part B ASP Pricing Limits
"Section 303(c) of the Medicare Modernization Act of 2003 (MMA) revised the payment methodology for Part B covered drugs that are not
paid on
a cost or prospective payment basis. In particular, section 303(c) of the MMA amended Title XVIII of the Act by adding section 1847A,
which established a new average sales price (ASP) drug payment system. Beginning January 1, 2005, drugs and biologicals not paid on a
cost or prospective payment basis will be paid based on the ASP methodology, and payment to the providers will be 106 percent of the ASP.
The ASP methodology uses quarterly drug pricing data submitted to the CMS by drug manufacturers. CMS will supply contractors with the ASP
drug pricing files for Medicare Part B drugs on a quarterly basis." (reference: www.cms.gov)
The table below lists the Medicare ASP pricing limits for CSL Behring products. This table will be updated quarterly.
All codes listed in this table are for informational pruposes and not a guarantee of reimbursement. The HCPCS codes provided are
based on CMS guidelines. The billing party is solely responsible for coding of drugs and services (eg, HCPCS Coding). Because government
and other third-party payor coding requirements change periodically, please verify currnet coding requirements directly the the payor
being billed.
Effective dates for Q1 are
January 1, 2009 - March 30, 2009. Dates for Q2 are April 1, 2009 - June 30, 2009.
CSL
Product |
HCPCS Code | Code Descriptor | Billing Unit |
Q1 2009 | Q2 2009 |
| Carimune NF | J1566 | Injection, immune globulin,
lyophilized |
ea 500 mg | 29.429 |
31.018 |
| Cytogam | J0850 | Injection, cytomegalovirus immune
globulin intravenous (human) |
ea vial | 878.825 | 878.825 |
| Helixate FS | J7192 | Factor VIII (antihemophilic factor (recombinant)) |
ea IU | 1.078 | 1.082 |
| Humate P | J7187 | Injection, von Willebrand factor
complex (Humate P®) |
ea
VWF:RCO IU | 0.881 | 0.888 |
| Monoclate P | J7190 | Factor VIII (antihemophilic factor (human)) |
ea IU | 0.858 | 0.851 |
| Mononine | J7193 | IX (antihemophilic factor, purified,
non-recombinant) |
ea IU | 0.902 | 0.905 |
| Privigen | J1459 | Injection, immune Globulin (Privigen®)> |
ea 500 mg | 34.155 | 35.189 |
| Rhophylac | J2791 | Rhophylac® Injection |
ea 100 iu | 5.242 | 5.237 |
| Vivaglobin | J1562 | injection, immune Globulin (Vivaglobin®) |
ea 100 mg | * | * |
| Zemaira | J0256 | Injection, alpha1–proteinase
inhibitor, human |
ea 10 mg | 3.712 | 3.678 |
Effective dates for Q3 are
July 1, 2009 - September 30, 2009. Dates for Q4 are October 1 - December 31, 2009
CSL
Product | HCPCS Code | Code Descriptor | Billing Unit | Q3 2009 | Q4
2009 |
| Carimune NF | J1566 | Injection, immune globulin,
lyophilized | ea 500
mg | 30.893 | 30.405 |
| Cytogam | J0850 | Injection, cytomegalovirus immune
globulin intravenous (human) | ea
vial | 878.823 | 878.825 |
| Helixate FS | J7192 | Factor VIII (antihemophilic factor (recombinant)) | ea
IU | 1.087 | 1.096 |
| Humate P | J7187 | Injection, von Willebrand factor
complex (Humate P®) | ea
VWF:RCO
IU | 0.881 | 0.880 |
| Monoclate P | J7190 | Factor VIII (antihemophilic factor (human)) | ea IU | 0.873 | 0.857 |
| Mononine | J7193 | IX (antihemophilic factor, purified,
non-recombinant) | ea
IU | 0.898 | 0.896 |
| Privigen | J1459 | Injection, immune Globulin (Privigen®)> | ea 500 mg | 35.095 | 35.052 |
| Rhophylac | J2791 | Rhophylac® Injection | ea 100 iu | 5.247 | 5.227 |
| Vivaglobin | J1562 | injection, immune Globulin (Vivaglobin®) | ea 100 mg | * | * |
| Zemaira | J0256 | Injection, alpha1–proteinase
inhibitor, human | ea 10
mg | 3.714 | 3.697 |
Reference:
http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a1_2009aspfiles.asp
* Vivaglobin, reference DME MAC websites:
http://www.cignagovernmentservices.com/jc/coverage/fees/2ndQRTR09Drug.pdf
http://www.ngsmedicare.com/NGSMedicare/DMEMAC/Claims/FeeSchedules/