It's a compound with a well-established history in clinical trials, giving researchers a solid foundation of data to build upon, even as new avenues of inquiry emerge in 2026
We reiterated our stance from the CY 2025 OPPS/ASC final rule with comment period, that if we were to use average sales price as the basis of calculating a payment, we believed there must be more consistent, validated, and universal reporting in order for ASP to be a viable payment methodology (89 FR 93961)
In the CY 2024 OPPS/ASC final rule with comment period, based on hospital statements that many hospitals could not calculate a payer-specific negotiated charge as their payer-specific negotiated charge was based on a percentage of billed charges or based on a formula or algorithm that may be determined after the episode of care, we finalized new data elements, the payer-specific negotiated charge percentage and the payer-specific negotiated charge algorithm, to provide MRF users with an understanding of how the payer-specific negotiated charge was calculated, and a contextual data element, the estimated allowed amount, which is a dollar amount reflecting the average of the historical reimbursement (allowed amount) received from a third party payer for an item or service, required to be displayed when no payer-specific negotiated charge dollar can be encoded
When you calculate cost per pound of fat lost, semaglutide may actually represent better value despite the higher sticker price, at least based on clinical trial data
