US · guidance
CMS Pub. 100-04, ch. 17, § 20.3
Calculation of the Payment Allowance Limit for DME MAC Drugs
Payments for drugs billed to the DME MACs will be based on the implementation of the MPDIMA,
beginning January 1, 2004, and will be paid at 85 percent of the AWP for HCPCS payment amounts
based on the April 1, 2003 fee schedule. Exceptions to this calculation are as follows:
The payment limits for infusion drugs furnished through an item of durable medical equipment on or
after January 1, 2004, will be 95 percent of the October 1, 2003 AWP.
• The payment limits for new drugs or biologicals will be 95 percent of the AWP. A new drug is
defined as an unlisted drug (not currently covered by a HCPCS code) that was FDA approved
subsequent to April 1, 2003. A drug would not be considered new if: The brand or
manufacturer of the drug changed; a new formulation of the vial size is developed; or the drug
received a new indication.
The payment limits for certain drugs studied by the OIG and GAO are based on the percentages of the
April 1, 2003 AWPs specified on Table 1 in §20.
Payment limits determined under this instruction shall not be updated during 2004.
History
(Rev. 397, Issued: 12-16-04, Effective: 01-01-05, Implementation: 01-03-05)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
4c0464ffb7abb4876a99ef68fd91d5f061e52f8bc5a46ffe5b21f8bb582cdcab
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