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CMS Releases Fourth Quarter Payment Rates for Drugs and Biologicals
The Centers for Medicare and Medicaid Services (CMS) issued their release for the CY2005 fourth quarter payment rates for those drugs covered under the Medicare Part B Program. This article will update the rates associated with plasma-derived and recombinant therapies. CMS has also released the fourth quarter payment rate for Alpha1- proteinase inhibitor therapies under The Hospital Outpatient Prospective Payment System (HOPPS).
BACKGROUND
Since January 1, 2005, reimbursement for certain drugs and biologicals covered under the Medicare Part B Program has been based upon an Average Sales Price (ASP) plus 6%. The ASP plus 6% reimbursement applies to all plasma-derived and recombinant therapies. CMS is updating the rates for these therapies on a quarterly basis based upon the ASP data and total units sold as submitted by each manufacturer within a given calendar quarter year. CMS will continue to use a six-month lag time between the data submitted and their actual reported payment rates for a given quarter (i.e. data submitted by manufacturers in the second Quarter of 2005 will be used to establish the payment rates for the fourth quarter 2005). The rates listed below will be in effect as of October 1, 2005. Note: Blood clotting factors receive an additional furnishing fee of $0.14 per unit above and beyond the ASP plus 6%. This furnishing fee is included in the total payment rates listed for blood clotting factors.
Fourth Quarter Medicare Part B Payment Rates
HCPCS Code |
Description |
Payment Rate |
| J0256 |
Injection, alpha1 – proteinase inhibitor, human, per 10 mg |
$3.28 |
| J2790 |
Rho(D), immune globulin, full dose, human, injections, per 300mcg |
$84.99 |
| J2792 |
Rho(D), immune globulin, IV, human, solvent detergent, per 100 units |
$13.73 |
| J7190 |
Factor VIII, anti-hemophilic factor, human, per unit |
$0.65 |
| J7192 |
Factor VIII, anti-hemophilic factor, recombinant, per unit |
$1.05 |
| J7193 |
Factor IX, anti-hemophilic factor, purified, per unit |
$0.87 |
| Q2022 |
von Willebrand factor complex, human, per unit |
$0.87 |
| Q9941 |
Injection, immune globulin, intraveneous, lyophilized, per 1 gram |
$42.57 |
| Q9942 |
Injection, immune globulin, intraveneous, lyophilized, per 10 mg |
$0.43 |
Fourth Quarter Alpha1 – proteinase inhibitor rate under HOPPS
Under HOPPS the payment rate for those therapies designated as orphan drugs by CMS, which includes Alpha1 therapies, the reimbursement rates are adjusted quarterly based upon the higher of 88% of the Average Wholesale Price (AWP) or 106% of the Average Sales Price (ASP) for the entire therapeutic class. As such, the fourth quarter payment rate has been set at $3.68 per 10 mg.
ZLB Behring will continue to update provider’s and patient’s who rely on our plasma-derived and recombinant therapies for treatment as to the changes occurring within the Insurance and reimbursement arena. Questions or concerns as they pertain to Reimbursement Alert can be directed to our Toll-Free Reimbursement Answerline at 1-800-676-4266.
ZLB Behring assumes no responsibility for the individual interpretation of any material, facts, or references provided within the context of its publication of Reimbursement alert.
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Reimbursement Alert September 2005
ZLB Behring assumes no responsibility for the individual interpretation of any material, facts, or references provided within the context of its publication of Reimbursement alert.
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