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Many surgeons value Omidria's ability
to maintain pupillary dilation during
cataract surgery, but is the luxury of
operating through a wide pupil worth
$465?
That's the question surgical centers
and hospitals have been grappling with
since Dec. 31, when Omidria's "pass-
through" payment status expired —
and with it the ability for them to bill
separately for the drug. Without pass-through status,
CMS won't pay separately for Omidria.
Congress established the pass-through provision in
the Medicare law to encourage advances in health
care. Pass-through status lets CMS track utilization of
new products and drugs before deciding if they war-
rant inclusion in the cataract bundled payment. As an incentive,
CMS pays providers extra to use "pass-through" drugs and devices,
letting them bill for such products outside of the bundled payment in
which they are used.
An ASC, for example could bill Medicare Omidria's wholesale price
of $465 plus 6%. That's nearly $500 in addition to the standard facil-
ity fee bundle.
But when the pass-through ends after 3 years, the incentive
becomes an impediment and the focus shifts from the drug's effi-
cacy to its economics. Without receiving separate reimbursement,
it's fair to question whether Omidria is now cost-prohibitive. A facility
REIMBURSEMENT WATCH
Omidria's Future Without Pass-Through Status
• COST-PROHIBITIVE? Omidria,
which is administered through
balanced saline solution to help
manage small pupils and improve
post-op healing, has lost its
"pass-through" status, meaning it
will no longer be reimbursed sep-
arately.
