3.3.1 The
Centers for Medicare and Medicaid Services (CMS) Healthcare Common
Procedure Coding System (HCPCS), National Level II Medicare
J codes
are to be priced using the following.
3.3.1.1 Drugs (except for home infusion
drugs) administered other than oral method, including chemotherapy
drugs, are to be priced from the Medicare Average Sales Price (ASP).
3.3.1.2 Drugs that do not appear on
the Medicare ASP file will be priced at the lesser of billed charges
or 95% of the Average Wholesale Price (AWP). Effective August 15,
2019, vaccines that appear on the Centers for Disease Control and
Prevention (CDC) Private Sector Vaccine Price List and do not appear
on the Medicare ASP file will be priced at 106% of the CDC rate.
Vaccines that are neither on the CDC price list nor the Medicare
ASP file will be priced at 95% of the AWP. Vaccines with more than
one CDC Private Sector Vaccine price (per Current Procedural Terminology
(CPT) code) will be averaged prior to applying the 106%. CDC vaccine
pricing will be updated quarterly and included in the Quarterly
Injectable Drug Updates.
3.3.1.3 Home infusion drugs provided
on or after January 30, 2012: Home infusion drugs must be provided in
accordance with the TPM,
Chapter 8, Section 20.1. Home infusion drugs
will be paid the lesser of the billed amount or 95% of the AWP only
in cases where the home infusion drug is not available through the
TPharm, or the beneficiary is not required by the TPM,
Chapter 8, Section 20.1 to obtain the drug
from the TPharm. Home infusion drugs not provided through the TPharm
will be billed using the appropriate
J code or any
other appropriate HCPCS coding for home infusion drugs not appearing
on the Medicare ASP file along with a specific NDC. The unique HCPCS
code will facilitate agency reporting requirements for future data
analysis, while the NDC will be used in determining the drug’s AWP.
J-3490 (unclassified drug code) may be used in lieu of specific
HCPCS coding (e.g.,
J,
Q, and
S codes)
for reporting purposes as long as the drugs are FDA-approved and
have specific NDCs for pricing.
3.3.1.4 Effective January 1, 2017,
drugs infused through Durable Medical Equipment (DME) shall be priced
at ASP plus 6%, in accordance with Section 5004 of the 21st Century
Cures Act, and TRICARE’s requirement at 10 USC Section 1079 to reimburse
like Medicare, where practicable