Medicare

Physician's Office

Medicare is likely to cover and reimburse for Neulasta® when it is administered "incident to a physician's service" for a reasonable and medically necessary indication. Neulasta® must be:

• Furnished by and represent a cost to the physician
• Administered in the office by a physician or auxiliary personnel under the physician's supervision

As of January 1, 2005, Medicare reimbursement for Neulasta® is based on the average sales price (ASP). Medicare sets an allowable amount based on ASP plus 6% for drugs and biologics.

Medicare reimbursement is based on the lesser of this allowable amount or actual charges, as follows:

• Physician offices are reimbursed for 80% of the allowable amount
• The patient or patient's secondary insurer is responsible for the remaining 20% coinsurance

Hospital Outpatient

Medicare's hospital outpatient prospective payment system (OPPS), frequently referred to as the Ambulatory Payment Classification (APC) system, went into effect August 1, 2000.

Services paid under the Medicare hospital OPPS are assigned to APCs, and each APC is linked to a payment amount that represents the total payment to the hospital.

In addition, there are separate payments for some drugs, biologicals, and devices.

The Medicare hospital OPPS is used to reimburse for outpatient services provided in practically all types of hospitals, including:

• Acute care hospitals
• Cancer hospitals
• Eye and ear hospitals
• Rural hospitals
• Rehabilitation and psychiatric hospitals & units
• Children's hospitals
• Long-term care hospitals
• Trauma centers

The only hospitals not affected by Centers for Medicare and Medicaid Services' (CMS) OPPS are:

• Critical access hospitals
• Maryland hospital services included under state waiver and subject to Maryland's Health Services Cost Review Commission (HSCRC) oversight
• Indian Health Service hospitals

There are also 11 diagnosis-related group (DRG)-exempt cancer hospitals and several children's hospitals that qualify for additional protections. These hospitals are therefore able to recoup the difference between OPPS payments and reasonable cost payments under OPPS indefinitely.

If you have questions about Amgen products or whether your facility is affected by these or any other guidelines, contact the toll-free reimbursement information service provided by Amgen: the Reimbursement Connection® at 1-800-272-9376.

Neulasta® is reimbursed by Medicare under the APC system.

• CMS has assigned HCPCS code J2505 for Neulasta® used in the hospital outpatient setting on or after January 1, 2004
• Reimbursement for Neulasta® use for non-ESRD patients in 2007 is based on average sales price (ASP) plus 6 percent.

Hospital Inpatient

Medicare inpatient benefits are covered under Medicare Part A.

Inpatient services are paid using a prospective payment system (PPS).

• Payment amounts are based on the DRG to which the case is assigned
• DRG assignment depends on a patient's diagnosis and the services provided
• All drugs provided on an inpatient basis are included in the DRG-based payment
• Medicare does not pay separately for drugs, including Neulasta® administered in an inpatient setting

Pharmacy

The Medicare Part D Prescription Drug Benefit went into effect January 1, 2007. However, CMS does not plan to move Part B drugs such as, Neulasta®, to Part D. In general, Neulasta® will continue to be accessed through the Part B benefit.

Medigap

Some Medicare beneficiaries have Medigap plans that cover prescription drugs (policies H, I, and J). If those individuals enroll in a Part D plan, their Medigap drug coverage will no longer be valid. However, their Medigap plan will continue to cover Part B related services, including covered Part B drugs administered in the physician's office or hospital outpatient setting.

 

The Reimbursement Connection® (1-800-272-9376) can conduct insurance verifications to confirm whether a patient's Medigap or supplemental plan covers Neulasta®.

© 2007 Amgen All Rights Reserved. Prescribing Information for Neulasta®