FAIC Act

Separate Medicare payments for costly cancer drugs

This bill would, beginning in 2026, require separate Medicare payments for certain high-cost cancer drugs given in hospital outpatient departments. A drug would qualify if it was FDA-approved on or after January 1, 2008, does not have transitional pass-through status, and would otherwise be packaged into an OPD payment. The year 2026 threshold would be $350 mean per day product cost and would increase each year by the OPD fee schedule increase factor. The separate payment would equal the drug's average sales price (ASP), or if ASP is not available, the wholesale acquisition cost (WAC), or if neither is available, the mean unit cost from hospital claims. The Secretary would adjust other payments so total yearly Medicare spending stays the same; this could raise or lower beneficiaries' coinsurance and out-of-pocket costs.