2005 Medicare Part B Drug Payment Allowance Limits
Effective 1/1/2005, the payment allowance limits for drugs not included in the Average Sales Price (ASP) Medicare Part B Drug Pricing File are based on the published wholesale acquisition cost (WAC) or invoice pricing. WPS is requiring an invoice to be submitted with claims for NOC drug procedure codes J3490, J9999 and J3590 as well as drugs not included in the ASP Medicare Part B Drug Pricing File per CP-REV-348, CR 3539, effective 1/1/2005, until the WAC pricing is acquired by all carriers.
The files below contain the actual payment amounts that will be used to pay for Part B covered drugs for the first quarter of 2005. The payment amounts are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufacturers for the third quarter of 2004. The price changes are the result of updated and, in some cases, corrected data from the manufacturers of these drugs. In most cases, there are not substantial changes between second- and third-quarter price data.
Prices for chemotherapy and inhalation drugs remain within the price range identified by the General Accountability Office (GAO), and which GAO concluded would lead to sufficient provider reimbursement. Overall, the revenue impacts on particular types of providers are very similar to those reported in the Physician Payment Rule using second quarter data.
For additional background on the recent Medicare Part B price changes, please see the GAO report "Medicare Chemotherapy Payments: New Drug and Administration Fees Are Closer to Providers' Costs" (GAO-05-142R) available on the GAO Web site at:
www.gao.gov/docsearch/abstract.php?rptno=GAO-05-142R
To access the most up-to-date information on the Medicare Part B Drugs Average Sales Price (ASP) Information Resource page on the CMS Website, go to:
http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/
To read CMS' MLN Matters article regarding the 2005 Payment Allowance Limits for Medicare Part B Drugs from November 2004, please go to the following Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3232.pdf (pdf - 2 pages; 270KB)
