Major Biosimilar Reimbursement Surprise! – 12/19/22

Major Biosimilar Drug Reimbursement Surprise for January 2023

CMS has released the ASP file for HCPCS effective January 1, 2023.


Major Changes for 2023:


  • CMS has increased payments for Biosimilar drugs to ASP of the biosimilar drug plus 8% of the ASP of the reference product.


  • Most biosimilar reimbursements have dropped significantly from October to January indicating aggressive price competition among biosimilars.


  • Reference drug reimbursement rates hold steady.


  • January 2023 HCPCS codes and Payment limits are available NOW on BuyandBill.com


Biosimilar Reimbursement Trends October 2022 to January 2023

HCPCS Code

Biosimilar Drug Name

Reference Drug

Payment Limit October 2022

Payment Limit January 2023

Change

% Change

Q5123

RIABNI

Avastin

$48.60

$49.75

$1.15

2.37%

Q5118

ZIRABEV

Avastin

$38.66

$33.69

-$4.97

-12.85%

Q5107

MVASI

Avastin

$30.31

$31.70

$1.39

4.57%

Q5106

RETACRIT

Epogen/Procrit

$8.13

$8.06

-$0.07

-0.87%

Q5105

RETACRIT

Epogen/Procrit

$0.81

$0.81

-$0.01

-0.86%

Q5101

ZARXIO

Epogen/Procrit

$0.27

$0.24

-$0.04

-12.82%

Q5117

KANJINTI

Herceptin

$32.70

$33.37

$0.67

2.06%

Q5116

TRAZIMERA

Herceptin

$40.01

$33.20

-$6.81

-17.02%

Q5124

BYOOVIZ

Lucentis

#N/A

$235.95

#N/A

#N/A

Q5122

NYVEPRIA

Neulasta

$171.38

$146.65

-$24.72

-14.43%

Q5120

ZIEXTENZO

Neulasta

$135.55

$89.94

-$45.61

-33.65%

Q5111

UDENYCA

Neulasta

$163.60

$137.66

-$25.94

-15.86%

Q5110

NIVESTYM

Neupogen

$0.40

$0.36

-$0.04

-10.50%

Q5108

FULPHILA

Neupogen

$141.11

$136.54

-$4.57

-3.24%

J1447

GRANIX

Neupogen

$0.39

$0.41

$0.01

3.05%

Q5121

AVSOLA

Remicade

$36.42

$33.50

-$2.92

-8.01%

Q5104

RENFLEXIS

Remicade

$48.65

$45.47

-$3.18

-6.53%

Q5103

INFLECTRA

Remicade

$30.95

$24.80

-$6.14

-19.84%

Q5119

RUXIENCE

Rituxan

$39.74

$32.68

-$7.06

-17.76%

Q5115

TRUXIMA

Rituxan

$53.02

$48.83

-$4.19

-7.90%

Q5114

OGIVRI

Rituxan

$45.32

$42.60

-$2.72

-6.00%

Q5113

HERZUMA

Rituxan

$52.97

$36.40

-$16.57

-31.29%

Q5112

ONTRUZANT

Rituxan

$63.12

$58.34

-$4.78

-7.57%

Refererence Product Payment Limit Trends October 2022 to January 2023

HCPCS Code

Reference Drug

Payment Limit October 22

Payment Limit January 2023

Change

% Change

J9035

Avastin

$69.72

$70.75

$1.03

1.48%

J0885

Epogen/Procrit

$8.37

$8.25

-$0.13

-1.49%

J9355

Herceptin

$84.40

$82.74

-$1.66

-1.96%

J2778

Lucentis

$258.41

$237.20

-$21.21

-8.21%

J2506

Neulasta

$131.41

$135.17

$3.75

2.86%

J1442

Neupogen

$0.99

$0.98

-$0.01

-0.71%

J1745

Remicade

$35.02

$34.86

-$0.16

-0.46%

J9312

Rituxan

$82.25

$81.75

-$0.50

-0.61%