CMS Updates Medicare Part B Drug Prices

CMS Updates Medicare Part B Drug Prices

Retroactive code pricing updates may require claims lookback.

The Centers for Medicare & Medicaid Services (CMS) has posted a retroactive update to the April Average Sales Price (ASP) pricing file for three Medicare Part B drugs. Also now available are the July ASP and Not Otherwise Classified (NOC) pricing files and the ASP NDC HCPCS crosswalk.

April ASP Update

On June 1, CMS retroactively updated the ASP for three HCPCS Level II codes. The updated payment limits are affective April 1, 2021, through June 30, 2021.

CodeShort DescriptionDosagePayment Limit
J1557Gammaplex injection500 mg$49.452
J3315Triptorelin pamoate injection3.75 mg$515.485
Q2050Doxorubicin injection10 mg$308.818

The ASP for these codes change again in third quarter.

July ASP Update

The following table shows updated payment limits for five HCPCS Level II codes, effective July 1, 2021, through Sept. 30, 2021:

CodeShort DescriptionDosagePayment Limit
J1437Ferric derisomaltose injection10 mg$25.815
J1951Fensolvi injection0.25 mg$127.748
J3032Eptinezumab-jjmr injection1 mg$15.603
J7212Factor viia (recomb sevenfact)1 mcg$2.185
Q5123Riabni injection10 mg$73.83

Take Note

Payment allowance limits subject to the ASP methodology are based on first quarter 2021 (1Q21) ASP data. The absence or presence of a HCPCS Level II code and the payment allowance limits in the pricing files does not indicate whether Medicare covers a drug. Determinations are made by the local Medicare Administrative Contractor processing the claim.

Where applicable, the payment amounts in the quarterly ASP files are 106 percent of the ASP calculated from data submitted by drug manufacturers. The quarter-to-quarter price changes are generally the result of updated data from the manufacturers of these drugs.

According to CMS, comparing the third quarter 2021 payment amounts with the prior quarter reveals that, on average, payment amounts for the top 50 Part B drugs decreased by 0.8 percent. For most of the higher volume drugs (26 out of the top 50), the prices changed 2 percent or less. Overall, the prices for 21 of the top 50 drugs decreased.

HCPCS Quarterly Update Correction

CMS updated on June 9 the July 2021 Alpha-Numeric HCPCS File to make several corrections, as shown below:

HCPCS/MOD CodeActionShort DescriptionLong DescriptionEffective DateTOSBETOSCovPricing
C9065Do not terminate
G0327Revise TOS7/1/20215
J9314Remove code
M0201AddCOVID-19 vaccine home adminCOVID-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only COVID-19 vaccine administration is performed at the patient’s home6/8/2021VO1GC54
M0247AddSotrovimab infusionIntravenous infusion, sotrovimab, includes infusion and post administration monitoring5/26/2021VO1GC54
M0248AddSotrovimab inf, home adminIntravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency5/26/2021VO1GC54
Q0247AddSotrovimabInjection, sotrovimab, 500 mg5/26/2021VO1GC54

Lee Fifield
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Lee Fifield has a Bachelor of Science in communications from Ithaca College, New York, and has worked as a writer and editor for more than 15 years.

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