Most carriers will base vaccine payments as a percentage of the average wholesale price (AWP) or the average sales price (ASP).

AWP is the national average price assigned to a vaccine or drug by its manufacturer and is compiled by various vendors such as Thomson's Red Book (which is different from the AAP Red Book), First Databank or Medi-Scan for use by carriers. In general, the AWP is the cost of the vaccine plus (depending on the vendor) a 20-25 percent mark-up and excise tax. Carriers will purchase the AWP calculations from one of these vendors. Below is a chart on AWP calculations by the vendors.

Vendor AWP calculation​
Thomson Red Book​                    List price x 1.20 plus excise tax​
First Databank​                    List price x 1.25 plus excise tax​
MediScan​                    List price x 1.25 plus excise tax​

 

The AWP for a particular vaccine can be obtained by contacting the vaccine manufacturer (see below). In reviewing carrier vaccine payments, identify how the carrier determines AWP, i.e., which vendor is used and how frequently is the AWP updated.

ASP is based on quarterly sales reports by manufacturers to CMS on the sale prices of vaccines sold for that time period. For Medicare, vaccine payments are made at 106% of the ASP. In general, ASP is usually less than AWP because it reflects all sales of the vaccine, including volume discounts.

AWP and ASP updates: ASP data is updated quarterly. Depending on the vendor, AWP data is updated monthly or quarterly. In addition, there is a time lag (ranging from 1-3 months) for carriers to update their claims systems, and not all carriers may update their systems quarterly.

Obtaining AWP or ASP data: The AAP is currently evaluating options on facilitating access to updated AWP data. Due to vendor licensing agreements, there are restrictions on how the AWP data can be exchanged (such as posting lists of AWP on websites). Unlike the ASP, which is collected by the federal government through CMS, AWP is proprietary data by the vendors. In lieu of purchasing the AWP listings from the vendors, vaccine manufacturers have established reimbursement support programs that physician practices can call to obtain AWP information:

sanofi pasteur: Reimbursement Support Service – 800/822-2463

GlaxoSmithKline: Reimbursement Hotline – 888/822-2749

Merck: 800/734-6282

MedImmune: 800/949-3789

Wyeth: 800/666-7248

To obtain current ASP data, click here.  

For new vaccines on the market that have not yet had the AWP or ASP calculated, pediatricians need to check with the carrier on how vaccine payments will be based. Some may base it on a percentage of billed charges. Check your carrier contract. The AAP has developed the Vaccine Addendum to Carrier Contracts​ to address this situation and provide guidance when negotiating for vaccine payments.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.

Additional Resources

Last Updated

08/30/2021

Source

American Academy of Pediatrics