WASHINGTON - CMS released the latest average sales price data for nebulizer meds June 20, boosting reimbursement for albuterol so significantly that one industry watcher exclaimed: "It's the best thing to ever happen to the small provider." Others aren't so sure.
The biggest change: The single reimbursement amount for albuterol and Xopenex, now bundled under HCPCS code Q4094. Both drugs will be reimbursed at $1.31 per unit dose. That's up from 20 cents per dose for albuterol and down from $3.84 for brand-name Xopenex.
"We've had calls from 15 to 20 people who dropped out of the business wanting to get back in," said Mickey Letson, president of Decatur, Ala.-based Letco Companies.
The new reimbursement is based on the weighted average sales price for both drugs, but with providers unable to dispense Xopenex at that price, many fear only a short-term bump in price for albuterol.
"My personal feeling is that of July 1 nobody is going to be dispensing Xopenex anymore," said one California provider. "For the quarter beginning July 1, the price is ($1.31). Then, because you won't have any Xopenex, the price will drop and by quarter 1 of 2008, you'll have no Xopenex in the running total so reimbursement will go back to 20 cents."
Letson confirmed that since the fee schedule was released, he has seen 50% of his sales of Xopenex "go out the window."
Estimates on Sepracor's sales of Xopenex to Medicare patients range from 20% to 30%, sources say. Because ASP calculations are based on all sales of the drug, not just Medicare, any drop in reimbursement would be somewhat mitigated.
"The next two quarters you're likely to see an increase then I think it will level off mid next year," said Letson. "I don't think it will drop below a dollar."
Sepracor plans to offer a rebate to providers who use Xopenex, but with its price tag so much higher than albuterol, that won't be much of an incentive, Letson said.