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Overview

Overall PRD is here: Eli Lilly Kisunla PRD

DAG Overview​

The Eli Lilly Pricing DAG (eli_lilly_pricing) prices Kisunla-centered episodes for Medicare and Medicare Advantage.

Scope:​

Payers:

  • Medicare
    • Traditional Medicare pricing
  • Medicare Advantage for the following payers:
    • Aetna: 7
    • Humana: 522
    • UnitedHealthcare: 643

Providers:

Eli Lilly provided a list of target Health Systems. We use provider spines to identify the HCOs and their associated facilities. We also manually reviewed the list to remove facilities that would likely not provide infusion services.

  • Hospital Outpatient Facilities
  • Imaging Centers
  • Infusion Centers
Infusion Centers

Kisunla is only available at certain infusion centers - this information is managed by the Eli Lilly BI&A team through sales data. The file managed by the EL team does not contain Type 2 NPIs; it contains: facility name, address, city, state. EL has Type 1 NPIs in their database but they are (currently) unwilling to share that information with TQ.

We use a combination of fuzzy matching and manual review to map the infusion centers to Type 2 NPIs.

Episodes:

There are two episodes:

  1. AZ-001: Infusion Treatment Episode
    • Administration of Kisunla (donanemab-azbt, HCPCS J0175) via intravenous infusion (HCPCS 96365)
    • MRI brain imaging for diagnosis and monitoring (HCPCS 70551)
  2. AZ-002: Infusion-Only Episode
    • Administration of Kisunla (donanemab-azbt, HCPCS J0175) via intravenous infusion (HCPCS 96365)

SSPs:

  • UN000: Kisunla Infusion Treatment SSP
    • Subpackages:
      • 355UN: MRI without Contrast
  • RA005: MRI without Contrast SSP
    • Subpackages:
      • 161RA

Pricing​

Medicare​

We use the Medicare API to retrieve the Medicare prices associated with each bundle.

Hospitals:

For hospitals, we use the Medicare API to retrieve the facility fees (OPPS) and rely on reference data tq_production.reference_external.physician_reference_pricing for professional fees (MPFS). The Medicare API also requires gross charges because sometime there may be "lesser of" logic between the gross charge and the Medicare rate.

Imaging Centers:

For imaging centers, we surface the global rate for 70551 from MPFS, representing both the technical and professional components. Since we do not have gross charges available for Imaging Centers, we set an arbitrarily high gross charge to ensure that the Medicare rate is always used.

Infusion Centers:

For infusion centers, we retrieve the global rate for the infusion, 96365, from MPFS. Then manually add the drug cost for J0175 based on the average sales price (ASP) plus 6% (this is the value that is stored in tq_production.reference_internal.asp_reference_pricing). Since the medicare rate is reported at 2mg, we scale the price based on 350 units = a 700mg dose. For alternative dosages, the price will be adjusted proportionally on the frontend.

Since we do not have gross charges available for Infusion Centers, we set an arbitrarily high gross charge to ensure that the Medicare rate is always used.

Medicare Advantage​

For Medicare Advantage, we apply a flat multiplier of 105% to the Medicare prices.

Medicare Advantage

We consulted TQ subject-matter experts to understand how Medicare Advantage contracting typically works. In most cases, Medicare Advantage rates are structured as a flat percentage of Medicare—usually around 100% and sometimes up to 105%. Although some contracts may fall slightly below 100% or exceed 105%, these cases are uncommon.

Hospital MRF data does contain Medicare Advantage rates, but it is messy and difficult to cleanly infer a consistent percentage of Medicare. However, the hospital MRF data does contain additional_notes field that can sometimes be useful to extract a percentage of Medicare.

If we are able to extract a percentage of Medicare from the MRF additional notes for a provider-payer, we use that percentage. Otherwise, we default to 105% to reflect the higher end of typical Medicare Advantage contracting.

We also validated this expected range (100-105%, we majority of contracts falling at 100%) using our first-party contracts data.

Network Status Indication​

Medicare Advantage network status is determined for each payer-facility combination using MRF data and Komodo data.

We determine that a facility is in-network if either of the following is ture:

  • There exists a payer or hospital MRF rate for the health system and payer combination.
  • There exists a Komodo claim for the facility and payer combination.
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