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 purposes 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 current coding requirements directly the payor being billed.
Effective dates for Q1 are January 1 - March 31, 2012.
Dates for Q2 are April 1, 2011 – June 30, 2011. Effective dates for Q3 represent dates of service from July 1-September 30, 2011. Effective dates for Q4, reflect dates of service from October 1 – December 31, 2011.
CSL
Product |
HCPCS Code |
Code Descriptor |
Billing Unit |
Q1 2012 |
Q4 2011 |
| *Berinert® |
J0597
New 1/1/11 |
C1 Esterase Inhibitor (NOC File) |
Ea 10 IU |
$30.229 |
$30.229 |
| Carimune® NF |
J1566 |
Injection, immune globulin, lyophilized |
ea 500 mg |
$30.189 |
$31.044 |
| Corifact |
J7180
New Code Effective 1/1/2012 |
Factor XIII antihemophilic factor |
ea 1 iu |
$6.41 |
N/A |
| Cytogam® |
J0850 |
Injection, cytomegalovirus immune Globulin intravenous (human) |
ea vial |
$966.084 |
$966.084 |
| Helixate® FS |
J7192 |
Factor VIII (antihemophilic factor (recombinant)) NOS |
ea IU |
$1.113 |
$1.104 |
| *Hizentra™ |
J1559
New 1/1/11 |
Injection, Hizentra |
ea 100 mg |
$7.285 |
$7.285 |
| Humate® P |
J7187 |
Injection, von Willebrand factor complex
(Humate P®) |
ea
VWF:RCO
IU |
$0.886 |
$0.890 |
| Monoclate® P |
J7190 |
Factor VIII (antihemophilic factor (human)) |
ea IU |
$0.894 |
$0.859 |
| Mononine® |
J7193 |
IX (antihemophilic factor, purified, non-recombinant) |
ea IU |
$0.910 |
$0.901 |
| Privigen® |
J1459 |
Injection, immune Globulin (Privigen®) |
ea 500 mg |
$36.065 |
$35.080 |
| Rhophylac® |
J2791 |
Rhophylac® Injection |
ea 100 iu |
$5.188 |
$5.186 |
| RiaSTAP® |
J1680 |
Injection, Human Fibrinogen concentrate |
ea 100 mg |
HOPPS $72.94 |
HOPPS $72.94 |
| Zemaira® |
J0256 |
Injection, alpha1–proteinase
inhibitor, human |
ea 10 mg |
$3.815 |
$3.905 |
CSL
Product |
HCPCS Code |
Code Descriptor |
Billing Unit |
Q3 2011 |
Q2 2011 |
| *Berinert® |
J0597
New 1/1/11 |
C1 Esterase Inhibitor (NOC File) |
Ea 10 IU |
$30.226 |
$27.528 |
| Carimune® NF |
J1566 |
Injection, immune globulin, lyophilized |
ea 500 mg |
$31.088 |
$31.203 |
| Corifact |
J7180
New Code Effective 1/1/2012 |
Factor XIII antihemophilic factor |
ea 1 iu |
N/A |
N/A |
| Cytogam® |
J0850 |
Injection, cytomegalovirus immune Globulin intravenous (human) |
ea vial |
$965.543 |
$939.807 |
| Helixate® FS |
J7192 |
Factor VIII (antihemophilic factor (recombinant)) NOS |
ea IU |
$1.102 |
$1.104 |
| *Hizentra™ |
J1559
New 1/1/11 |
Injection, Hizentra |
ea 100 mg |
$7.284* |
$7.284 |
| Humate® P |
J7187 |
Injection, von Willebrand factor complex
(Humate P®) |
ea
VWF:RCO
IU |
$0.879 |
$0.882 |
| Monoclate® P |
J7190 |
Factor VIII (antihemophilic factor (human)) |
ea IU |
$0.886 |
$0.882 |
| Mononine® |
J7193 |
IX (antihemophilic factor, purified, non-recombinant) |
ea IU |
$0.897 |
$0.897 |
| Privigen® |
J1459 |
Injection, immune Globulin (Privigen®) |
ea 500 mg |
$35.053 |
$35.115 |
| Rhophylac® |
J2791 |
Rhophylac® Injection |
ea 100 iu |
$5.182 |
$5.186 |
| RiaSTAP® |
J1680 |
Injection, Human Fibrinogen concentrate |
ea 100 mg |
HOPPS $72.89 |
HOPPS $72.89 |
| Zemaira® |
J0256 |
Injection, alpha1–proteinase
inhibitor, human |
ea 10 mg |
$3.867 |
$3.871 |
Reference: Medicare ASP and **HOPPS Pricing Files:
www.cms.gov
* Vivaglobin/Hizentra DME Pricing information, reference at DME MAC Fee schedules:
DME MAC A:
www.medicarenhic.com
DME MAC B:
www.ngsmedicare.com
DME MAC C:
www.cignagovernmentservices.com
DME MAC D:
www.noridianmedicare.com/dme/