Nine Overpriced Drug Codes, and CMS Won't Say Which

The OIG memo that went to CMS on August 10 runs two pages, names no drug, and ends with a sentence about file transfer.

Nine Part B drug codes cleared the statutory pricing threshold in the first quarter of 2026. Their average sales prices beat their average manufacturer prices by more than 5% for two straight quarters, or for three of the last four, which is exactly the condition CMS wrote into its own rule for lowering what it pays.

Another 12 codes cleared 5% in Q1 2026 on complete AMP data and missed on one of the other criteria.

The memo tells CMS to review the nine and decide whether to cut. Then it says this:

"We will provide you with the results of our pricing comparison for the first quarter of 2026. This information will be transmitted via our secure file transfer system."

So the list exists, it is nine codes long, it is sitting with the Administrator, and you cannot read it.

What a Referral Actually Does to a Code

Section 1847A(d) of the Act obliges the OIG to compare ASPs against AMPs every quarter and tell the Secretary when a drug's ASP runs 5% or more above its AMP. Once that happens, the Secretary may throw out the ASP and pay the lesser of the widely available market price or 103% of the AMP.

CMS narrowed that itself in the November 2012 final rule and started substituting in April 2013. It acts only on the two-of-two or three-of-four pattern, only where the ASP and AMP comparisons cover the same set of products, never where the substituted amount would come out above the ASP-based amount, and never on a drug the FDA has flagged as in short supply.

Four filters, and the reason to care about all of them is that a code surviving them gets repriced without anything you would recognize as a rule change.