by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Apr 25th, 2016 - Reviewed/Updated Aug 7th
Single Drug Pricer (SDP): Effective January 1, 2003, contractors pay drug claims on the basis of the prices shown on the SDP files, if present, SDP includes the HCPCS Drug pricing file.
Part B Drug pricing is the payment amounts that will be used to pay for Part B covered drugs. The payment amounts can be paid to the provider or directly to the Beneficiary depending on how the claim was filed.
This is the maximum Medicare Part B will pay. This is not Part D coverage. (Part D is for Rx - Drug coverage for Beneficiaries).
ASP Drug pricing: Included the vast majority of drugs and biologicals not priced on a cost or prospective payment basis will be priced based on the average sales price (ASP) methodology.
- Beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) HCPCS code.
- The payment allowance limits for drugs and biologicals that are not included in the ASP Pricing for compounded drugs is performed by the local contractor.
- Medicare Part B Drug Pricing File or Not Otherwise Classified (NOC) Pricing File, other than new drugs that are produced or distributed under a new drug application (or other application) approved by the Food and Drug Administration, are based on the published Wholesale Acquisition Cost (WAC) or invoice pricing, except under OPPS where the payment allowance limit is 95 percent of the published AWP.
ESRD drugs furnished by both independent and hospital - based ESRD facilities, as well as specified covered outpatient drugs, and drugs and biologicals with pass -through status under the Outpatient Prospective Payment System(OPPS), will be priced based on the ASP methodology.
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.