Effective January 1, 2017, CMS payment for external infusion drugs furnished through a covered item of DME will be based on Section 1847A of the Social Security Act. This means that most of the payments will be based on the Average Sales Price of these drugs. Payments will no longer be limited to rates established by the Medicare Modernization Act of 2003, which were based at 95% of Average Wholesale Price (AWP) as of October 1, 2003.
As a result of the policy change, insulin reimbursement has increased from $2.80 to $9.832 per unit. The updated reimbursement rates are reflected in the CareCLAIM POS responses pharmacies are receiving.
Please contact your account executive with any questions you may have.