CMS Releases Most Favored Nation Drug HCPCS Codes List and Drug Pricing File for January 1 Implementation

December 18, 2020

The American Society of Clinical Oncology (the Society), an affiliated organization of the Association for Clinical Oncology (the Association), collectively known as ASCO, opposes the Most Favored Nation (MFN) drug pricing model and is actively advocating for its delay with the Centers for Medicare & Medicaid Services (CMS) and Congress, as well as through legal briefs. Should CMS persist in moving forward with this misguided model, ASCO will continue to provide resources for its implementation, such as what is included below.

Today CMS released two technical files related to the MFN Model along with brief billing information.

One file, the January 2021 MFN Model Drug HCPCS Codes List contains the 50 drugs included in the model with the HCPCS codes and dosage. The other file, the January 2021 MFN Model Drug Pricing File lists the drug payment amounts for the 50 MFN drugs. The drug pricing file is in effect from January 1, 2021 – March 31, 2021.

With two exceptions, all MFN drugs in 2021 have payment amounts equal to 75% applicable ASP + 25% MFN price. The exceptions are Pegloticase injection and Sipuleucel-t auto cd54+, which will be paid at 100% applicable ASP.

The per-dose alternative add-on payment amount for January 1, 2021 – March 31, 2021 is $148.73 per dose of an MFN Model drug. The payment amount will be updated quarterly. There is no beneficiary cost-sharing for the MFN add-on payment.

Billing information provided by CMS includes:

  • Claims for MFN Model drugs should be submitted using the appropriate HCPCS code. Medicare claims processing systems will apply the MFN Drug Payment Amount, or the non-model (ASP) payment amount if it is lower.
  • The new HCPCS code M1145 (MFN drug add-on, per dose) will be used to bill for the alternative add-on payment amount for each dose of an MFN Model drug that is billed on the claim. “Per dose” means a claim line for an MFN Model drug.
  • Line items for M1145 must include a billed amount/charge. Entities paid under the Outpatient Prospective Payment System may use a token charge. The claims system will apply the lesser of the allowed amount or the billed amount for other entities.
  • Do not bill the MFN alternative add-on payment for claim lines with the JW modifier. Do not bill the MFN alternative add-on payment for drug claim lines that are not included on the MFN Model Drug HCPCS Codes List.

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