Pricing Comparison for Blood Disorder Treatments

This pricing comparison table illustrates the relationship of published pricing benchmarks commonly used by state Medicaid agencies and the Medicare program for ingredient cost reimbursement of blood disorder products to the average acquisition cost (AAC) for these products.

Although these specialty blood disorder products are not required to be reimbursed at AAC, CMS believes that this table will be helpful for states to use for analyzing, understanding and monitoring the relationship of AAC pricing to commonly used pricing benchmarks.

When evaluating the adequacy of total Medicaid reimbursement for blood disorder product claims, the professional dispensing fee should be adequate to assure access consistent with 1902(a)(30)(A). Guidance to states concerning Medicaid coverage and reimbursement for clotting factors, anti‐hemophilia drugs and other services provided to Medicaid beneficiaries with blood disorders can be found in the Medicaid Drug Rebate Program Notice, State Release No. 182.

When proposing a change to a reimbursement methodology, state Medicaid programs are required to submit a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) for review and approval.

This table will be updated semi-annually.