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Recommendation Followup Memo: Excluding Noncovered Versions When Setting Payment for Part B Drugs

In a November 2017 report, OIG found that CMS and a Federal court interpret relevant statute to require the inclusion, in limited circumstances, of versions of drugs not generally covered under Part B when setting Medicare payment amounts. This interpretation resulted in Medicare and its beneficiaries paying an extra $366 million from 2014 through 2016 for two high-cost drugs. OIG recommended that CMS seek a legislative change that would provide the agency flexibility to determine when non-covered versions of a drug should be included in Part B payment amount calculations. CMS did not concur with our recommendation, citing concerns related to beneficiary access and operational implications. This study will examine the financial costs to Medicare and its beneficiaries of continuing to include noncovered versions when setting Part B amounts in 2017 and 2018. It will also provide data to address CMS's concerns about potential beneficiary access issues related to our earlier recommendation.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
November 2019 Centers for Medicare & Medicaid Services Recommendation Followup Memo: Excluding Noncovered Versions When Setting Payment for Part B Drugs Office of Evaluation and Inspections OEI-BL-20-00100 2020