CMS sets 2013 reimbursement rate for Medicare Part B drugs

CMS will use the statutory reimbursement rate for separately billable drugs and biologics used in hospital outpatient settings for 2013, which could lead to more predictable reimbursement. CMS set the 2013 reimbursement rate under Medicare Part B for drugs and biologics at the average sales price (ASP) plus 6%. By law, CMS is permitted to use ASP plus 6% as a default rate for payment of hospital outpatient drugs. CMS said the rate covers drug acquisition costs and pharmacy overhead and applies to drugs and biologics without pass-through status. Both Biotechnology Industry Organization (BIO) and Pharmaceutical Research and Manufacturers of America (PhRMA) supported CMS's use of the statutory reimbursement rate. The details came in the 2013 final rule for Medicare's outpatient prospective payment system (OPPS), which CMS released on Nov. 1.

Previously, CMS used a variety of methodologies to calculate the reimbursement rate for drugs and biologics, which led to varying reimbursement rates of ASP plus 4-6%. In the 2013 final rule, CMS acknowledged that these methodologies "may not appropriately account for average acquisition and pharmacy overhead cost" and can result in payment rates that are not as "predictable, accurate, or appropriate as they could be." In comments submitted to CMS on the proposed rule, BIO said the 2013 policy "will provide predictable, appropriate" reimbursement rates "instead of continuing to modify an already complicated rate-setting methodology." ...