CSP Payer and Reimbursement Models 2 — Questions and Answers
Question 1: Under the standard Medicare Part B payment methodology, most separately payable physician-administered drugs are reimbursed at what rate?
- AWP minus 15%
- WAC plus 3%
- NADAC plus a dispensing fee
- ASP plus 6% (Correct answer)
Correct answer: ASP plus 6%
Medicare Part B pays most separately billable drugs at Average Sales Price plus a 6% add-on.
Question 2: A qualifying biosimilar under the Inflation Reduction Act temporarily receives which Part B add-on payment?
- AWP minus 20%
- WAC plus 10%
- ASP plus 8% of the reference product's ASP (Correct answer)
- ASP plus 6% of its own ASP
Correct 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.
Question 3: Which code set is used to bill a physician-administered specialty drug on a medical claim?
- NCPDP reject codes
- CPT Category III codes
- DRG codes
- HCPCS Level II J-codes (Correct answer)
Correct 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.
Question 4: Which electronic standard is used to submit pharmacy-benefit claims for specialty drugs to a PBM?
- ANSI X12 837I
- HL7 FHIR R4 only
- NCPDP Telecommunication Standard D.0 (Correct answer)
- CMS-1500 paper form
Correct answer: NCPDP Telecommunication Standard D.0
Retail and specialty pharmacy claims are adjudicated in real time via the NCPDP Telecommunication Standard version D.0.
Question 5: In a buy-and-bill model, who purchases the specialty drug and bears the financial risk before reimbursement?
- The patient
- The PBM
- The manufacturer
- The provider or clinic (Correct answer)
Correct 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.
Question 6: White bagging refers to which distribution arrangement?
- The patient picks up the drug and carries it to the clinic
- The manufacturer ships free drug directly to the patient's home
- The clinic buys the drug from a wholesaler and bills the medical benefit
- A specialty pharmacy dispenses a patient-specific drug and ships it to the provider site for administration (Correct answer)
Correct 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.
Question 7: Why are manufacturer copay cards generally prohibited for patients enrolled in Medicare Part D?
- CMS requires all copays be paid by Medigap
- Part D plans do not have cost sharing
- They may violate the federal Anti-Kickback Statute (Correct answer)
- Copay cards only work for generic drugs
Correct 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.
