2021 ASP Drug Pricing Files

ASP Drug Pricing Files October 2021 Update

The files below contain the payment amounts that will be used to pay for Part B covered drugs for the fourth quarter of 2021. The October 2021 ASP payment limits have been updated.

Comparing the fourth quarter 2021 payment amounts with the prior quarter reveals that, on average, payment amounts for the top 50 Part B drugs decreased by 0.6 percent.

For most of the higher volume drugs (36 out of the top 50), the prices changed 2 percent or less. Overall, the prices for 24 of the top 50 drugs decreased. In general, among the top drugs with a decrease, there are a number of competitive market factors at work – multiple manufacturers, alternative therapies or market shifts to lower priced products.

CMS remains interested in ensuring continued beneficiary access to Part B covered drugs. We will continue to monitor trends in pricing, as reflected by the published ASP payment rates, as well as utilization within the Medicare community.

Where applicable, the payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufacturers. The quarter to quarter price changes are generally the result of updated data from the manufacturers of these drugs.

The Medicare Part B payment limits for valid HCPCS codes that are not included in the quarterly ASP pricing files will be determined by the local Medicare contractor.

CMS guidance requires physicians and other providers to bill using the appropriate HCPCS or CPT code and to accurately report the units of service. Physicians and other providers should ensure that the units billed do not exceed the maximum number of units per day based on the code descriptor, reporting instructions associated with the code, and/or other CMS local or national policy.

Effective January 1, 2017, payment for infusion drugs furnished through a covered item of DME will be based on Section 1847A of the Social Security Act, meaning that most of the payments will be based on the Average Sales Price of these drugs. The ASP Drug Pricing Files for 2017 and subsequent years will no longer contain columns for the Infusion AWP or the DME infusion limit. Unless otherwise specified, the Payment Limit in column D will be applied to payments for drugs infused through covered DME. Additional information of DME Infusion Drug Pricing is available through the DME MACs.

Section 405 of the Consolidated Appropriations Act, 2021 requires the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) to conduct periodic studies on certain self-administered drugs or biologicals that are paid under the statutory payment limit, and permits CMS to apply a “lesser-of” methodology to the ASP calculation, if deemed appropriate. The Medicare payment amount for the drug or biological billing code would be the lesser of (“lesser of” methodology): (1) the payment limit determined using the current ASP+6% methodology, or (2) the ASP+6% amount obtained by excluding the self-administered products identified an OIG study.

Section 405 also requires that beginning July 1, 2021, the ASP-based payment for billing codes that include certain self-administered products identified in a July 2020 OIG report (available at https://oig.hhs.gov/oei/reports/OEI-BL-20-00100.asp) be calculated using the “lesser of” methodology.

To meet the implementation date of July 1, 2021 required by section 405, CMS has applied the lesser-of methodology to the payment limit calculations for billing and payment codes representing certolizumab pegol and abatacept (J0717 and J0129, respectively). These have been incorporated into the July 2021 ASP Drug Pricing Files and a notation of the lesser-of methodology has been included in the July 2021 ASP Pricing File.

Page Last Modified:
09/09/2021 04:06 PM