Medical Injectable Reimbursement Changes

Transcription

1 STAT Bulletin Community Blue Traditional Blue PO Box 80 Buffalo, New York March 25, 2011 Volume 17: Issue 11 To: All MD, DO, Skilled Nursing Facilities and Home Infusion Pharmacies Contracts Affected: All Lines of Business Medical Injectable Reimbursement Changes Effective July 1, 2011, there will be a change in our reimbursement methodology for provider-administered medical injectable drugs. The cost of pharmaceuticals is escalating at a rate far greater than the overall rate of inflation, placing a significant burden on the nation s health care system. Medical injectable drugs are consuming an ever-larger part of the health care dollar, and in our case, the member premium dollar. Currently, Medicare pays Average Sales Price plus 6 percent (ASP plus 6%). BlueCross BlueShield of Western New York has decided to adopt a more equitable approach than ASP plus 6% and will be implementing a drug reimbursement program that is built on the following principles: establishment of a reimbursement model based on a variable fee schedule that encourages the use of generic medications where appropriate the use of the Average Sales Price (ASP) methodology support of a physician buy and bill model for drugs administered in the physician s office; and quarterly updates to allowed amounts for drugs, reflecting acquisition cost changes throughout the year This change in reimbursement methodology will also apply to drugs administered in a skilled nursing facility that are not included in the standard per diem payment, as well as medical drugs billed by Home Infusion Pharmacies. BlueCross BlueShield has used a market-based approach since July, Our new reimbursement program will have a three-tier structure: Tier one: Includes oncology support drugs, moderately priced agents, and older drugs where there are often significant average wholesale price (AWP)/ASP differentials. Drugs in this tier will be reimbursed at ASP plus 15% B WNY C9013.Pub CC 5510 A Division of HealthNow New York Inc. An Independent Licensee of the BlueCross BlueShield Association. C9013

2 Tier two: High-cost chemotherapy agents to be reimbursed at ASP plus 10%, which is comparable to AWP minus 18% and significantly higher than the Medicare allowed amount of ASP plus 6%. Tier three: Maximum Allowable Cost (MAC) allows for increased reimbursement for select generics and injectable drugs in classes with therapeutic equivalents. All other drugs without an ASP will be reimbursed at AWP minus 15% until an ASP is available. A select list of Administration Codes has been modified in conjunction with this change; the codes are listed on the enclosed attachment with the associated new rates. The attachment details the new reimbursement methodology, including allowed amounts for generic medications and chemotherapy agents. The new fee schedule information will be available on our secure provider website, as of April 1, If you have any questions regarding this bulletin, please contact your Provider Relations Account Specialist at

3 Chemotherapy Administration Codes Code Description Final Rate Chemo, anti-neopl, sq/im $ Chemo hormone antineopl sq/im $ Chemo, iv push, sngl drug $ Chemo, iv push, addl drug $ Chemo, iv infusion, 1 hr $ Chemo, iv infusion, addl hr $ Chemo prolong infuse w/ pump $ Chemo iv infus each addl seq $ Chemotherapy, intracavity $ Chemotherapy, into CNS $ Refill/maint, portable pump $ Refill/maint pump/resvr syst $

4 Sample Injectable Drug Fee Schedule (Injectable Drug Fee Schedules to be updated quarterly) Tier 1: ASP +15% : Code Brand Dose Final Rate J0129 Orencia 10 MG $ J0881 Aranesp 1 MCG $ 3.21 J0885 Procrit 1000 Unit $ J0886 Epogen 1000 Unit $ J1745 Remicade 10 MG $ J2505 Neulasta 6 MG $ 2, J2820 Leukine 50 MCG $ J3315 Trelstar 3.75 MG $ J9010 Campath 10 MG $ J9025 Vidaza 1 MG $ 5.56 J9225 Vantas 50 MG $ 1, J9293 Mitoxantrone/ Novantrone 5 MG $ J9351 Hycamtin 4 MG $ J9001 Doxil 10 MG $ *rates are approximate and may fluctuate slightly due to changes in CMS ASP pricing that will occur between April 1 and July 1. 4

5 Sample Injectable Drug Fee Schedule (Injectable Drug Fee Schedules to be updated quarterly) Tier 2: ASP +10% : Code Brand Dose Final Rate J2353 Sandostatin 1 MG $ J9035 Avastin 10 MG $ J9041 Velcade 0.1 MG $ J9055 Erbitux 10 MG $ J9201 Gemzar 200 MG $ J9263 Eloxatin 0.5 MG $ 9.49 J9305 Alimta 10 MG $ J9310 Rituxan 100 MG $ J9355 Herceptin 10 MG $ *rates are approximate and may fluctuate slightly due to changes in CMS ASP pricing that will occur between April 1 and July 1. 5

6 Tier 3: MAC Code Brand Dose Final Rate J1561 Gamunex 500 MG $ J1626 Kytril 100 MCG $ 2.24 J2405 Zofran 1 MG $ 0.88 J2430 Aredia 30 MG $ J2469 Aloxi 25 MCG $ J2503 Macugen 0.3 MG $1, J2778 Lucentis 0.1 MG $ J3487 Zometa 25 MCG $ J7321 Hyalgan Per dose $ J7323 Euflexxa Per dose $ J7324 OrthoVisc Per dose $ J7325 Synvisc/ Synvisc-One 1 MG $ J9000 Adriamycin 1 MG $ 6.98 J9040 Blenoxane 15 units $ J9045 Carboplatin 50 MG $ J9060 Cisplatin 10 MG $ J9130 DTIC-Dome 100 MG $ J9171 Taxotere 1 MG $ J9181 VePesid 10 MG $ 3.47 J FU 500 MG $ 2.37 J9202 Zoladex 3.6 MG $ J9217 Eligard 7.5 MG $ J9264 Abraxane 1 MG $ 9.50 J9265 Taxol 30 MG $ J9390 Navelbine 10 MG $