CSP Payer and Reimbursement Models 2

Question 1

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

Accepted Answer

ASP plus 6%

Answer

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?

Accepted Answer

ASP plus 8% of the reference product's ASP

Answer

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?

Accepted Answer

HCPCS Level II J-codes

Answer

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?

Accepted Answer

NCPDP Telecommunication Standard D.0

Answer

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?

Accepted Answer

The provider or clinic

Answer

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

CSP - Certified Specialty Pharmacist Practice Test