All items below must be true.

• Facility is reimbursed under Outpatient Prospective Payment System (OPPS)
• Drug has a status indicator K
• Drug being subject to Average Sales Price (ASP) + 6% reimbursement methodology
• Line-item billed with modifier JG

Calculator Use

• Select appropriate drug pricing year and quarter file for dates of service billed
  • See CMS Medicare Part B Drug Average Sales Price Data webpage
• Enter amount into ASP field
• Calculator will return single unit reimbursement amount

Calculator Exceptions

Items below are not considered when calculating reimbursement:

• Patient responsibility
• Sequestration
• Other primary payer
• If drug is reimbursed under other methodology besides ASP + 6%

Calculation Explanation

Calculator equation is set to:

• (X/1.06) * 0.775 = reimbursement
  • X is ASP dollar amount, which includes a 6% markup
  • 1.06 is markup value
  • 0.775 leaves amount of reimbursement left (as opposed to calculating reduction, which would have used 0.225)

Still have questions on reimbursement? Call the Noridian Provider Contact Center.