Following bipartisan leadership efforts in the Senate and House of Representatives, Congress enacted legislation that directed the Centers for Medicare & Medicaid Services (CMS) to grant an extension of pass-through reimbursement until October 1, 2020 to OMIDRIA and several other drugs. Pass-through status allows reimbursement for OMIDRIA separate from the packaged Ambulatory Payment Classification (APC) reimbursement for the cataract surgery procedure. CMS sets the payment rate at Average Sales Price (ASP)
- No copay in hospital outpatient departments (HOPDs)21
- 20% copay in ambulatory surgery centers (ASCs)21
- Approximately 90% of Medicare Part B patients have some form of supplemental insurance, which covers copays22
Based on currently available information and subject to change without notice. Individual plan coverage, policies, and procedures may vary and should be confirmed. Omeros does not guarantee coverage or payment.
No effect on physician fees21
Payment to the surgeon for cataract surgery under Medicare's Physician Fee Schedule will be unaffected by the use of OMIDRIA or the pass-through payments related to OMIDRIA, now and in the future.
No effect on the healthcare system21
The pass-through regulation is budget-neutral to the healthcare system. To the extent that ophthalmic surgeons/facilities elect not to access pass-through payments, the funds set aside will be used by other specialties. Any remaining amount will be lost to the system.
OMIDRIA has a unique billing code
Injection, phenylephrine and ketorolac, 4-mL vial
ASCs and HOPDs will use this unique HCPCS code to bill CMS and other payers for separate payment.*
*HOPDs=Hospital Outpatient Departments; HCPCS=Healthcare Common Procedure Coding System.Learn More About OMIDRIAssure
Information contained herein is provided as a reference for obtaining appropriate and accurate reimbursement for the use of OMIDRIA in eligible patients. Omeros Corporation does not guarantee that the use of the recommended codes will result in reimbursement.