Medicare finalizes ASP-plus-six reimbursement rate for outpatient drugs

Abstract

After years of trying to accurately determine outpatient drug and pharmacy costs, the Medicare program is scrapping its formulas and applying a simpler system for 2013—reimbursement at the drugs’ average sale price (ASP) plus 6%. The reimbursement rate, published in the November 15 Federal Register, appears in the Centers for Medicare and Medicaid Services (CMS) final rule for the 2013 Medicare hospital outpatient prospective payment system (OPPS). The ASP-plus-6% rate applies to drugs and biologics that are not packaged within an ambulatory payment classification group because their average cost per day of treatment exceeds $80. CMS refers to these as “separately payable” drugs. For 2013, the reimbursement rate for separately payable drugs is the same as that for the 26 pharmaceutical products that have what the CMS calls “transitional pass-through” status. Pass-through drugs are new, high-cost products whose reimbursement rate is set by statute for a period of two to three years (see table).