This segment is from RJ Health's On-Demand Webinar:
Shedding Light on Medically Covered Specialty Drug Pricing Methods
Presented by:
Christopher Webb, CPhT
Director, Product Development
&
Jason Young, PharmD
SVP, Clinical Data Operations
For more webinars: [ Ссылка ]
For more information contact: info@reimbursementcodes.com
Jason Young: Great, thanks Chris. So, Chris has introduced several different price types and some history behind these price types, how they're derived and also how they translate into code level reimbursements. So, what we're going to do now is we're going to spend some time looking through a few different methodologies that somebody could apply to actually process and reimburse for medically covered prescription drugs. We're going to primarily focus in here on physician administered claims, a lot of, we talked about the hospital outpatient and a lot of that follows the APC scheme. So, we will carry through some of that pricing, but we're generally focusing here on the physician office claims and we're going to walk through a series of methodologies. The first methodology is, probably considered the most basic; we're looking at a code level reimbursement. So, the code level we're referring to is the HCPCS or CPT code level and really this is going to be driven by the HCPCS unit submitted. So, there are a few different ways to look at this. As we explained there is an AWP based code level reimbursement and, as Chris mentioned, typically when you're dealing with AWP pricing you're going to be applying a discount to the AWP rate, as we know that those AWPs are generally inflated above the actual price that somebody would pay for that drug. Typical discounts that we see applied range anywhere from five to fifteen percent off of the AWP rate. The WAC based code level is, again, generated off that wholesale acquisition cost price. So, now we're talking a little better representation of the actual cost of a drug at first sale. So, in this case if a plan was going to use WAC based code level reimbursement they're generally going to apply a mark-up to that when they actually reimburse the claim. This allows for some profit on the actual providers side that they’re purchasing that drug and administering it. So, sort of inverse to the AWP here. We usually see a mark-up of anywhere between 5-50% off of those WAC based prices. The last one being the Average Sales Price or Medicare allowable; as we know Medicare sets that as an ASP plus six. But generally, we will see plans use that same base ASP rate and apply different mark ups to that, sometimes in the neighborhood of eight to ten percent. One important part about the Medicare allowable ASP pricing, a consideration is that it’s not available for all HCPCS codes, so if you're going down the path of using an ASP based reimbursement model, you have to keep in mind that you're going to need an alternate strategy for those codes for which there is no CMS published ASP.
