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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 each quarter reflect dates of service for:

Q1 are Jan 1 - March31

Q2 are April 1 – June 30

Q3 are July 1 - September 30

Q4 are October 1 – December 31

CSL
Product
HCPCS Code Code Descriptor Billing Unit Q3 2016 Q2 2016
Berinert® J0597 C1 Esterase Inhibitor ea 10 IU 46.529 46.322
Carimune® NF J1566 Injection, immune globulin, lyophilized ea 500 mg 34.033 35.018
Corifact® J7180 Factor XIII antihemophilic factor ea 1 IU 8.190 7.774
Cytogam® J0850 Injection, cytomegalovirus immune Globulin intravenous (human) ea vial 1126.963 1064.770
Helixate® FS J7192 Factor VIII (antihemophilic factor (recombinant)) NOS ea IU 1.196 1.181
*Hizentra® J1559 Injection, Hizentra ea 100 mg 9.835 9.837*
Humate-P® J7187 Injection, von Willebrand factor complex
(Humate P®)
ea
VWF:RCO
IU
1.035 0.996
Kcentra® C9132 Prothrombin complex concentrate (human), Kcentra, per i.u. of Factor IX activity ea IU HOPPS 1.77 HOPPS 1.69
Monoclate-P® J7190 Factor VIII (antihemophilic factor (human)) ea IU 0.978 0.964
Mononine® J7193 IX (antihemophilic factor, purified, non-recombinant) ea IU 1.112 1.123
Privigen® J1459 Injection, immune Globulin (Privigen®) ea 500 mg 38.233 38.255
Rhophylac® J2791 Rhophylac® Injection ea 100 IU 4.811 4.731
RiaSTAP® J7178
Injection, Human Fibrinogen concentrate ea 1 mg HOPPS 1.14 HOPPS 1.09
Zemaira® J0256 Injection, alpha1–proteinase
inhibitor, human
ea 10 mg 4.606 4.595

* CMS updated the April 2016 ASP Pricing File on 5/31/2016 to reflect the correct CSL Behring pricing submission for Hizentra for the period of April 1, 2016 to June 30, 2016. You may rebill claims in July 2016 to be paid at a level consistent with the revised rates. Please check with your Medicare carrier for rebilling instructions /criteria.

 

CSL
Product
HCPCS Code Code Descriptor Billing Unit Q1 2016 Q4 2015
Berinert® J0597 C1 Esterase Inhibitor (NOC File) ea 10 IU 46.322 40.516
Carimune® NF J1566 Injection, immune globulin, lyophilized ea 500 mg 34.895 33.106
Corifact® J7180 Factor XIII antihemophilic factor ea 1 IU 7.774 7.413
Cytogam® J0850 Injection, cytomegalovirus immune Globulin intravenous (human) ea vial 1064.770 1064.770
Helixate® FS J7192 Factor VIII (antihemophilic factor (recombinant)) NOS ea IU 1.177 1.162
*Hizentra® J1559 Injection, Hizentra ea 100 mg 8.469 8.469
Humate-P® J7187 Injection, von Willebrand factor complex
(Humate P®)
ea
VWF:RCO
IU
0.996 0.990
Kcentra® C9132 Prothrombin complex concentrate (human), Kcentra, per i.u. of Factor IX activity ea IU HOPPS 1.69 HOPPS 1.62
Monoclate-P® J7190 Factor VIII (antihemophilic factor (human)) ea IU 0.959 0.961
Mononine® J7193 IX (antihemophilic factor, purified, non-recombinant) ea IU 1.096 1.074
Privigen® J1459 Injection, immune Globulin (Privigen®) ea 500 mg 38.255 38.050
Rhophylac® J2791 Rhophylac® Injection ea 100 iu 4.731 4.748
RiaSTAP® J7178 Injection, Human Fibrinogen concentrate ea 1 mg HOPPS 1.09 HOPPS 1.05
Zemaira® J0256 Injection, alpha1–proteinase
inhibitor, human
ea 10 mg 4.593 4.447


Reference: Medicare ASP and **HOPPS Pricing Files: www.cms.gov

* 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.cgsmedicare.com
DME MAC D: www.noridianmedicare.com/dme/

CRP16-05-0001 05/2016
© 2016 CSL Behring