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Decision Guide · the math, shown
Every buy-and-bill conversation starts with “Medicare pays ASP+6.” The check that clears is smaller, and the difference is statutory, not negotiable. Here is the full chain — with a worked example from the current CMS file that updates every quarter.
The payment limit is 106% of ASP. Medicare pays 80% of that and sequestration trims its share 2% (→ 78.4%); the patient or secondary owes the other 20%. Fully collected, you recover 98.4% of the allowable — about ASP+4.3%. Fail to collect coinsurance, discard unbillable waste, or float the inventory too long, and the real net drifts toward ASP+2% or below.
A typical 35-unit (70-kg, 5 mg/kg) Crohn’s dose. Numbers recompute each quarter from the CMS file.
| Payment limit per 10 mg (Q3 2026) | $31.48 |
| Implied ASP per 10 mg (limit ÷ 1.06) | $29.70 |
| Allowable per dose (35 units) | $1,101.76 |
| Medicare pays (80% × 98%) | $863.78 |
| Coinsurance to collect (20%) | $220.35 |
| Recovered if fully collected | $1,084.14 |
| Effective add-on over ASP | +4.3% |
Run the same math on any of the 1,474 codes with the calculator — or see how each drug’s limit has moved.
Medicare pays 80% of the allowable and the patient or secondary pays 20%. The 2% budget sequester applies to Medicare's 80% share only — 80% × 98% = 78.4% — so a fully-collected claim recovers 78.4% + 20% = 98.4% of the allowable. Since the allowable is 106% of ASP, the practice recovers 98.4% × 106% ≈ 104.3% of ASP: an effective add-on of about 4.3%, not 6%.
No. The sequester touches only the federal share. But that cuts both ways: a fifth of the reimbursement rides on actually collecting coinsurance from patients and secondary payers. Every uncollected coinsurance dollar comes straight out of the add-on — on a thin-margin drug, a few percent of failed collection erases the entire spread.
Manufacturer ASP already nets out most discounts, but a practice's acquisition price often includes distributor prompt-pay terms (typically ~2%) that the ASP benchmark also reflects. Industry analyses commonly put the realistic net spread closer to ASP+2–3% once collection shortfalls, waste outside JW billing, and carrying cost are counted. The honest statement: ASP+6 is the ceiling; your operations decide how much of the 4.3% you keep.
CMS publishes the payment limit quarterly (the ASP pricing file — officially the Medicare Part B Drug Payment Limit File), computed from manufacturer sales two quarters back. The current file is Q3 2026, covering 1,474 codes. Every change is ranked on our ASP-change leaderboard.
Related: buy-and-bill vs white bagging · net cost recovery (NCR) · this quarter’s payment-limit changes. For the coding side of any drug (units, modifiers, patient cost), see CareCost Estimate.
Drug economics as of Q3 2026 (Medicare ASP basis)
The practice X-Ray computes your real recovery — acquisition vs ASP, collection rates, waste, and the commercial book Medicare math can’t see.