Payer and Reimbursement Models Flashcards

Under the standard Medicare Part B payment methodology, most separately payable physician-administered drugs are reimbursed at what rate?

Answer: ASP plus 6%

Medicare Part B pays most separately billable drugs at Average Sales Price plus a 6% add-on.

A qualifying biosimilar under the Inflation Reduction Act temporarily receives which Part B add-on payment?

Answer: ASP plus 8% of the reference product's ASP

The IRA raised the add-on for qualifying biosimilars to 8% of the reference product's ASP for a five-year period.

Which code set is used to bill a physician-administered specialty drug on a medical claim?

Answer: HCPCS Level II J-codes

Physician-administered drugs are typically billed under the medical benefit using HCPCS Level II J-codes with units and NDCs.

Which electronic standard is used to submit pharmacy-benefit claims for specialty drugs to a PBM?

Answer: NCPDP Telecommunication Standard D.0

Retail and specialty pharmacy claims are adjudicated in real time via the NCPDP Telecommunication Standard version D.0.

In a buy-and-bill model, who purchases the specialty drug and bears the financial risk before reimbursement?

Answer: The provider or clinic

In buy-and-bill, the provider acquires inventory, administers the drug, and then bills the payer under the medical benefit.

White bagging refers to which distribution arrangement?

Answer: A specialty pharmacy dispenses a patient-specific drug and ships it to the provider site for administration

White bagging ships patient-specific medication from a specialty pharmacy directly to the administering provider, often billed under the pharmacy benefit.

Why are manufacturer copay cards generally prohibited for patients enrolled in Medicare Part D?

Answer: They may violate the federal Anti-Kickback Statute

Manufacturer copay assistance for federal health program beneficiaries can be considered remuneration inducing use of federally reimbursed drugs under the Anti-Kickback Statute.