Transitional Pass-Through Payment and Permanent HCPCS Codes Negotiated for Orphan Drugs

A specialty biopharmaceutical company developed two drugs for the treatment of rare diseases and wanted to seek premium payment in a predominantly Medicaid market.

The JD LYMON Solution: We prepared transitional pass-through and HCPCS applications for two infusion drugs.

Results: The transitional pass-through status was granted for both drugs enabling a payment mechanism available upon drug launch. The preliminary decision for the HCPCS codes was not favorable, but after a meeting with CMS staff to review the economic and therapeutic story, this decision was reversed. Once permanent J-codes were granted for the drug, this provided a seamless reporting and payment method, enabling access to these medicines for patients with life-altering conditions.

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