Thyrogen Medicare Part B Payment Allowance Limits

Thyrogen® (thyrotropin alfa for injection)
Medicare Part B Reimbursement: Physician Office and Hospital Outpatient Setting
(Effective October 1, 2014- December 31, 2014)
Sequestration Budget Cuts - Activated on 4/1/2013: Medicare Part B total reimbursement changed from ASP+ 6% to ASP+ 4.3%
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Medicare Part B reimburses physicians at 80% of the allowed amount (the allowed amount = ASP+6% or 86% of ASP) ;
Per Sequestration Budget Cuts, Medicare needed to reduce this by 2% (2% discount). This translates to a decrease of 1.7% (2%*(80%+6%)=1.7%) – reducing the
reimbursement rate to physicians of ASP+6% to ASP+4.3%. .
There is no reduction on the beneficiary’s 20% co-payment responsibility. In other words, this cut only applies to the amount that Medicare will pay the physician.
The beneficiary (patient) is responsible for the same amount as prior to this change: 20% of ASP+6%.
This reduction on Medicare Part B allowed amount changes total reimbursement to ASP+4.3% inclusive of the patient’s co-payment.
ICD-9
Code
HCPCS/
J-Code
CPT- 4
(Procedure
Code)
Medicare Part B
2% Reduction Payment
(ASP+6% x 80%-2%)
Medicare Patient
Co-payment
(ASP+6% x 20%)
Medicare Part B Total
Reimbursement Payment
(ASP+4.3%)
1 Vial:*
58468-0030-1
193
J3240
96372
$1,121.45
$286.09
$1,407.54
2 Vials/Kit:
58468-1849-4
193
J3240
96372
$2,242.90
$572.18
$2,815.08
NDC Code
*Drug is not sold per vial. Must purchase 2 Vials/Kit
-Medicare reimbursement for Q3, 2014 is based on Q1, 2014 Average Sales Price (ASP) data.
-Co-payment is the responsibility of the patient’s secondary insurance or the patient if the patient does not have secondary insurance and is to be collected/billed by the
physician office or the hospital outpatient setting.
Calculations for sequestration and its reduction on ASP+6% reimbursement:
 2% reduction on Medicare payment rate, 80% of allowed amount or ASP + 6%: (Q3, CMS ASP+6 % for Thyrogen is $1,431.81 per 0.9 mg)
 [ASP + 6%] x [80%-2%]=
 $1, 431.81 x 80%-2%= $1,121.45 per 0.9 mg (This is the amount Medicare will pay the provider)
 Beneficiary or Patient Co-insurance Amount is 20% of allowed charges at ASP + 6%:
 [ASP + 6%] x 20%=
 $1,431.81 x 20% = $286.09 per 0.9 mg (This is the amount that the beneficiary/patient will pay)
 Total Medicare payment under sequestration is ASP + 4.3%:% reduction on Medicare payment amount + Beneficiary/Patient co-insurance amount=
$1,121.45 + 286.09= $1,407.54 per 0.9 mg
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