May 4, 2023
Reduces Coinsurance for Certain part B Medical Drugs
Medicare members may see lower out-of-pocket costs for certain Part B drugs and biologicals with prices that have increased faster than the rate of inflation. For these drugs and biologicals, the beneficiary coinsurance will be 20% of the inflation-adjusted payment amount, which is less than what the beneficiary would otherwise pay.
The Centers for Medicare & Medicaid Services (CMS) posts the Medicare Part B Quarterly Sales Pricing (ASP) file which includes payment information for Part B rebatable drugs. These drugs are subject to the coinsurance adjustments. The list is in effect April 1 through June 30, 2023 and highlights the drugs that need to be adjusted. You can view the file at CMS.gov. We also have a link posted on our Medical Advantage policy web page under Pharmacy Part B policies. CMS has the right to adjust and may change this list of drugs quarterly.
Medicare members may experience coinsurance amounts that are lower than what they would have paid before the new law passed by as much as $1 - $372 per average dose. The savings apply to drugs given at a doctor’s office. Retail or mail order drugs are not included.
Claims
To avoid member and provider confusion, Premera will correct and finalize all medical drug claims from non-delegated provider systems by matching the HCPCS codes from CMS before sending. However, if Premera finds a previously paid claim needs to be adjusted, Premera will correct the coinsurance and the provider will be notified that they’ll need to reimburse the member for any paid overages.