Comparing Average Sales Prices and Average Manufacturer Prices for Medicare Part B Drugs: An Overview of 2012

摘要

Medicare and its beneficiaries spent $13.6 billion for Part B drugs in 2012.5 Although Medicare paid for more than 700 outpatient prescription drug HCPCS codes that year, spending for Part B drugs was concentrated on a relatively small subset of those codes. In 2012, 72 HCPCS codes accounted for 90 percent of the expenditures for Part B drugs; only 16 of these codes represented the majority of Part B drug expenditures. Reimbursement Methodology. The Social Security Act (the Act) mandates that the Office of Inspector General (OIG) compare average sales prices (ASPs) with average manufacturer prices (AMPs).1 The Act states that if OIG finds that the ASP for a drug exceeds the AMP by a certain percentage (currently 5 percent), the Secretary of Health and Human Services (the Secretary) may disregard the ASP for the drug when setting reimbursement amounts.2, 3 The Act further states: 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.