Excluding noncovered versions when setting payment for two Part B drugs would have resulted in lower drug costs for Medicare and its beneficiaries Issue brief (United States Department of Health and Human Services, Office of Inspector General) United States. Department of Health and Human Services Centers for Medicare & Medicaid Services (U.S.) Healthcare common procedure coding system Drug Costs Insurance, Pharmaceutical Services -- economics Medicare Part B -- economics Prospective Payment System Medicare coverage for outpatient prescription drugs is primarily provided under the voluntary Part D benefit. However, a limited number of prescription drugs-generally those that are injected or infused in physicians' offices or hospital outpatient settings-are covered under Medicare Part B. With certain exceptions, Part B does not cover drugs that are usually self-administered by patients, including drugs administered by self-injection. Medicare payment amounts for most Part B drugs are based on manufacturer-reported average sales prices (ASPs). In general, manufacturers must provide the Centers for Medicare & Medicaid Services (CMS) with the ASP and sales volume for each of their Part B national drug codes (NDCs) on a quarterly basis. However, Medicare sets payment amounts and reimburses providers for Part B drugs using another type of code, the Healthcare Common Procedure Coding System (HCPCS) code rather than NDCs. Because more than one NOC may meet the definition of a particular HCPCS code, CMS must first "crosswalk" manufacturers' NDCs to their matching HCPCS codes. To determine the quarterly Part B payment amount for a HCPCS code, CMS calculates a volume-weighted ASP using the ASPs and sales volumes for each of the corresponding NDCs. In some cases, "corresponding" NDCs may include versions that, despite containing the same drug/formulation, are not typically used in situations that meet Part B drug coverage criteria. In other words, under certain circumstances, criteria for including drugs in payment amount calculations may differ from criteria for covering a drug under Part B. Previous OIG work has found that inaccuracies in CMS's ASP data may have affected Medicare payments for a small number of drugs. This current data brief addresses a similar issue, whereby CMS may be including noncovered, self-administered versions (i.e., NDCs) of certain drugs when calculating Part B payment amounts. [Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, November 2017 United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body. Technical Report Text Illustrations 1 online resource (1 PDF file (15 pages)) nlm:nlmuid-101737981-pdf 101737981 http://resource.nlm.nih.gov/101737981 English United States The National Library of Medicine believes this item to be in the public domain. https://creativecommons.org/publicdomain/mark/1.0