Comparison of Fourth-Quarter 2009 Average Sales Prices and Average Manufacturer Prices: Impact on Medicare Reimbursement for Second Quarter 2010

摘要

Section 1847A(d)(2)(B) of the Social Security Act (the Act) mandates that the Office of Inspector General (OIG) compare Average Sales Prices (ASPs) to Average Manufacturer Prices (AMPs). If OIG finds that the ASP for a drug exceeds the AMP by a certain percentage (currently 5 percent), section 1847A(d)(3)(A) of the Act states that the Secretary of Health & Human Services (the Secretary) may disregard the ASP for the drug when setting reimbursement amounts. Section 1847A(d)(3)(C) of the Act goes on to state that ' the Inspector General shall inform the Secretary (at such times as the Secretary may specify to carry out this subparagraph) and the Secretary shall, effective as of the next quarter, substitute for the amount of payment the lesser of (i) the widely available market price (if any); or (ii) 103 percent of the average manufacturer price.'. Medicare Part B covers only a limited number of outpatient prescription drugs. Covered drugs include injectable drugs administered by a physician; certain self-administered drugs, such as oral anticancer drugs and immunosuppressive drugs; drugs used in conjunction with durable medical equipment; and some vaccines. To monitor Medicare reimbursement amounts based on ASPs and consistent with sections 1847A(d)(2)(B) and 1847A(d)(3) of the Act, OIG compared ASPs and AMPs to identify instances in which the ASP for a particular drug exceeded the AMP by at least 5 percent. This is OIGs 17th report comparing ASPs and AMPs, and it examines HCPCS codes with AMP data for every NDC that CMS used to establish reimbursement amounts, as well as HCPCS codes with only partial AMP data.