Which drugs have recently received pass-through status?

April 20, 2016
Medicare Web

Q: Our pharmacy is asking if there is going to be payment for a new anti-hemophilia factor called Nuwiq. They say it is quite expensive and they want to know if there is additional payment for it.

A: CMS has published 10drugs and biologicals that are eligible for pass-through payment as of April 1, and this item is on the list. The items, their corresponding HCPCS codes and APC assignments are listed in Table 2 of Transmittal 3471:

  • C9137, injection, Factor VIII (antihemophilic factor, recombinant) PEGylated, 1 I.U.
  • C9138, injection, Factor VIII (antihemophilic factor, recombinant) (Nuwiq), 1 I.U.
  • C9461, Choline C 11, diagnostic, per study dose
  • C9470, injection, aripiprazole lauroxil, 1 mg
  • C9471, Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg
  • C9472, injection, talimogene laherparepvec, 1 million plaque forming units (PFU)
  • C9473, injection, mepolizumab, 1 mg
  • C9474, injection, irinotecan liposome, 1 mg
  • C9475,injection, necitumumab, 1 mg
  • J7503, Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg

Be sure to check for any national or local coverage determinations based on any of these items, because assignment of a payable status indicator under the OPPS does not correlate to automatic coverage. Both components are required to insure appropriate billing and payment under the Medicare program.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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