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Drug Pricing and Reimbursement

This webpage pulls together the Office of Inspector General's (OIG) body of work since 2010 plus several older relevant items that relate to drug pricing and reimbursement in HHS programs. It features planned work, completed reports, industry guidance, and enforcement actions. It does not cover OIG's body of work focused on questionable or fraudulent billing for prescription drugs. The webpage on drug pricing and reimbursement will be updated periodically.


Spotlight Reports

Featured Reports

Report Title Area(s) of Work Issue Date Program
Increases in Reimbursement for Brand-Name Drugs in Part D (OEI-03-15-00080) Spending Trends 2018/06 Medicare Part D
CMS Did Not Always Provide Accurate Medicaid Unit Rebate Offset Amounts to State Medicaid Agencies (A-07-17-06074) Program Compliance 2018/05 Medicaid
Potential Misclassifications Reported by Drug Manufacturers May Have Led to $1 Billion in Lost Medicaid Rebates (OEI-03-17-00100) Data Integrity 2017/12 Medicaid
Excluding Non-covered Versions When Setting Payment for Two Part B Drugs Would Have Resulted in Lower Drug Costs for Medicare and its Beneficiaries (OEI-12-17-00260) Reimbursement Policy 2017/11 PART B
Reasonable Assumptions in Manufacturer Drug Price Reporting Under Medicaid (OEI-12-17-00130) Data Integrity 2019 Medicaid
FDA Approval Status of Drugs in the Medicaid Drug Rebate Program (OEI-03-17-00120) Data Integrity 2019 Medicaid
The Impact of Authorized Generics on Medicaid Drug Rebates (W-00-18-31499) Data Integrity, Program Compliance 2019 Medicaid
Accuracy of Drug Categorizations for Medicaid Rebates (OEI-03-08-00300) Data Integrity 2009/07 Medicaid
Average Manufacturer Price Determinations by Selected Drug Manufacturers Generally Were Consistent with Federal Requirements (A-06-13-00014) Data Integrity, Program Compliance 2014/06 Medicaid
Drug Manufacturers´┐Ż Non-Compliance with AMP Reporting Requirements (OEI-03-09-00060) Program Compliance, Data Integrity 2010/09 Medicaid
Limitations in Manufacturer Reporting of Average Sales Price Data for Part B Drugs (OEI-12-13-00040) Data Integrity, Program Compliance 2014/07 Medicare Part B
Quality of Sponsor Data Used in Calculating Coverage Gap Discounts (A-07-16-06067) Data Integrity, Program Compliance 2019 Medicare Part D
Concerns with Rebates in the Medicare Part D Program (OEI-02-08-00050) Incentive Alignment 2011/03 Medicare Part D
States' Collection of Rebates for Physician-Administered Drugs (OEI-03-09-00410) Program Compliance 2011/06 Medicaid
Annual Fee on Branded Prescription Drug Companies Under the Affordable Care Act (OEI-03-12-00560) Program Compliance 2014/04 Medicare Part D
States' Collection of Offset and Supplemental Medicaid Rebates (OEI-03-12-00520) Program Compliance 2014/12 Medicaid
States' Collection of Rebates for Drugs Paid Through Medicaid Managed Care Organizations Has Improved (OEI-05-14-00431) Program Compliance 2015/09 Medicaid
Medicaid Drug Rebate Dispute Resolution Could Be Improved (OEI-05-11-00580) Program Compliance, Data Integrity 2014/08 Medicaid
State Efforts to Exclude 340B Drugs from Medicaid Managed Care Rebates (OEI-05-14-00430) Program Compliance, Data Integrity 2016/06 Medicaid
States' Collection of Medicaid Rebates for Physician-Administered Drugs Program Compliance Various Medicaid
Medicare Part D Rebates Related to Drugs Dispensed by 340B Pharmacies Reimbursement Policy 2019 Medicare Part D
Least Costly Alternative Policies: Impact on Prostate Cancer Drugs Covered Under Part B (OEI-12-12-00210) Reimbursement Policy 2012/11 Medicare Part B
Medicare Could Collect Billions If Manufacturers Were Required To Pay Rebates for Part B Drugs (OEI-12-12-00260) Reimbursement Policy 2013/09 Medicare Part B
Update: Medicare Payments for End Stage Renal Disease Drugs (OEI-03-12-00550) Spending Trends, Reimbursement Policy 2014/03 Medicare Part B
Medicaid Drug Pricing in State Maximum Allowable Cost Programs (OEI-03-11-00640) Reimbursement Policy 2013/08 Medicaid
Medicaid Rebates for Brand-Name Drugs Exceeded Part D Rebates by a Substantial Margin (OEI-03-13-00650) Reimbursement Policy 2015/04 Medicare Part D
Part B Payments for 340B Purchased Drugs (OEI-12-14-00030) Reimbursement Policy 2015/11 Medicare Part B
CMS Should Address Medicare's Flawed Payment System for DME Infusion Drugs (OEI-12-16-00340) Reimbursement Policy 2016/09 Medicare Part B
Average Manufacturer Prices Increased Faster Than Inflation for Many Generic Drugs (A-06-15-00030) Spending Trends, Reimbursement Policy 2015/12 Medicaid
Calculation of Potential Inflation-Indexed Rebates For Medicare Part B Drugs 2017 (OEI-12-17-00180) Reimbursement Policy, Spending Trends 2017 Medicare Part B
Specialty Drug Pricing and Reimbursement in Medicaid (OEI-03-17-00430) Spending Trends, Reimbursement Policy 2019 Medicaid
High-Price Drugs are Increasing Federal Payments for Medicare Part D Catastrophic Coverage (OEI-02-16-00270) Spending Trends 2017/01 Medicare Part D
Replacing Average Wholesale Price: Medicaid Drug Payment Policy (OEI-03-11-00060) Reimbursement Policy 2011/07 Medicaid
Analyzing Changes to Medicaid Federal Upper Limit Amounts (OEI-03-11-00650) Reimbursement Policy 2012/10 Medicaid
Beneficiary Utilization of Albuterol and Levalbuterol Under Medicare Part B (OEI- 03-07-00440) Reimbursement Policy, Spending Trends 2009/08 Medicare Part B
Calculation of Volume Weighted Average Sales Price for Medicare Part B Prescription Drugs (OEI-03-05-00310) Data Integrity 2006/02 Medicare Part B
High Part D Spending on Opioids and Substantial Growth in Compounded Drugs Raise Concerns (OEI-02-16-00290) Spending Trends 2016/06 Medicare Part D
Accuracy of Part D Plans' Drug Prices Provided on the Medicare Prescription Drug Plan Finder (OEI-03-07-00600) Data Integrity 2009/07 Medicare Part D
Medicare Payments for Newly Available Generic Drugs (OEI-03-09-00510) Reimbursement Policy 2011/01 Medicare Part B
Medicaid Brand-Name Drugs: Rising Prices Are Offset by Manufacturer Rebates (OEI-03-10-00260) Reimbursement Policy 2011/08 Medicaid
Medicare Payments for Drugs Used to Treat Wet Age-Related Macular Degeneration (OEI-03-10-00360) Reimbursement Policy 2012/04 Medicare Part B
Medicaid Rebates for Physician-Administered Drugs (OEI-03-02-00660) Program Compliance 2004/04 Medicaid
Average Sales Prices: Manufacturer Reporting and CMS Oversight (OEI-03-08-00480) Program Compliance, Reimbursement Policy 2010/02 Medicare Part B
Manufacturer Safeguards May Not Prevent Copayment Coupon Use for Part D Drugs (OEI-05-12-00540) Program Compliance, Data Integrity 2014/09 Medicare Part D
Medicare Part B Prescription Drug Dispensing and Supplying Fee Payment Rates Are Considerably Higher Than the Rates Paid by Other Government Programs (A-06-12-00038) Reimbursement Policy 2014/09 Medicare Part B
Review of Additional Rebates for Brand-Name Drugs with Multiple Versions (A-06-09-00033) Reimbursement Policy 2010/03 Medicaid
Gaps in Oversight of Conflict of Interest in Medicare Prescription Drug Decisions (OEI-05-10-00450) Incentive Alignment 2013/03 Medicare Part D
Contract Pharmacy Arrangements in the 340B Program (OEI-05-13-00431) Program Compliance 2014/02 340B
Congressionally Mandated ASP/AMP Comparisons Data Integrity Ongoing Medicare Part B
Congressionally Mandated ASP/AMP Comparisons Data Integrity Various Medicare Part B
Medicare Part B Overpaid Millions for Selected Outpatient Drugs (A-09-14-02024) Program Compliance 2015/07 Medicare Part B

Featured Reports Table last updated: January 22, 2019.

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