Coverage Policy
The information displayed below pertains specifically to the Physician Office setting of care. For information tailored to the Hospital Outpatient setting or Pharmacy setting, please select the appropriate tab to the right. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. See below
Medicare
In general, Medicare considers subcutaneous injectable medications to be self-administered and, therefore, covered under Part D. However, Medicare covers FRAGMIN® under Part B when administered under a physician’s supervision and under Part D when dispensed for self-administration by a patient or caregiver. When provided as a Part B benefit, claims for FRAGMIN® are billed to contractors such as Fiscal Intermediaries (hospital outpatient setting), carriers (physician office setting) or the new Part A/B Medicare Administrative Contractors (MACs). Part D benefit claims for FRAGMIN® are billed to Part D plan sponsors. Providers should ensure that they are adhering to appropriate local contractor or Part D plan sponsor claim filing requirements when submitting claims for FRAGMIN®.
More information about Medicare Part B
Payor Reimbursement1
Medicare Part B reimbursement for FRAGMIN® in the physician office setting is based on Average Sales Price (ASP). Medicare sets an allowable payment amount, updated quarterly, at ASP plus 6%. 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 and the patient or patient’s secondary insurer is responsible for the remaining 20% coinsurance.
Administration Services
Medicare reimbursement for FRAGMIN® drug administration services provided in the physician office setting is based on the national fee schedule that is adjusted for geographic variations and updated annually. Medicare reimbursement is based on the lesser of the adjusted fee schedule amount or actual charges, as follows: physicians are reimbursed for 80% of the allowable amount and the patient or patient’s secondary insurer is responsible for the remaining 20% coinsurance.
1. Medicare Claims Processing Manual Chapter 17 Drugs and Biologicals, Section 20.1.2 Average Sales Price (ASP Payment Methodology). Information available on http://www.cms.gov/manuals/downloads/clm104c17.pdf. Accessed February 16, 2011.
