OFFICE OF INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
M P B D P :
EDICARE  ART    RUG  AYMENTS  
I P S B
MPACT OF  RICE  UBSTITUTIONS  ASED 
2015 A S P  
ON    VERAGE  ALES  RICES
Suzanne Murrin  
Deputy Inspector General 
for Evaluation and Inspections 
 
 
 
OEI-03-17-00360 
September 2017   
Report in Brief 
of  
September 2017 
 
OEI-03-17-00360 
 
Why OIG Did This Review   Medicare Part B Drug Payments:  Impact of Price 
When Congress established average sales 
Substitutions Based on 2015 Average Sales Prices 
price (ASP) as the basis for Medicare 
Part B drug reimbursement, it also  What OIG Found 
provided a mechanism for monitoring 
market prices and limiting potentially 
 CMS lowered Part B reimbursement for 13 drugs on the basis of 2015 data.  
excessive payment amounts.  The Social 
Security Act mandates that the Office of   CMSs price-substitution policy saved Medicare and its beneficiaries 
Inspector General (OIG) compare ASPs  $5.4 million over 1 year based on 2015 data. 
with average manufacturer prices 
(AMPs).  If OIG finds that the ASP for a   Medicare and its beneficiaries could have saved up to an additional 
drug exceeds the AMP by a certain  $17 million over 1 year if CMS implemented a more expansive 
percentage (currently 5 percent), the Act  price-substitution policy that, for example, allowed substitution for drugs 
directs the Secretary of Health and 
that exceeded the 5-percent threshold in a single quarter. 
Human Services to substitute the 
ASP-based payment amount with a lower 
Exhibit 1:  Results of the Medicare Part B 
calculated rate.  Through regulation, the 
Centers for Medicare & Medicaid  Price-Substitution Policy 
Services (CMS) outlined that it would 
make this substitution only if the ASP for 
a drug exceeds the AMP by 5 percent in 
the 2 previous quarters or 3 of the 
previous 4 quarters.  
Over the last decade, OIG has produced 
annual reports aggregating the results of 
our mandated quarterly ASP-to-AMP 
comparisons.  This annual report 
quantifies the savings to Medicare and its 
beneficiaries that are a direct result of 
CMSs price-substitution policy based on 
2015 average sales prices, and this report 
also offers recommendations for 
Source:  OIG analysis of ASP and AMP data from 2015 
achieving additional savings.   
What OIG Recommends   
How OIG Did This Review 
Because of the potential for savings to Medicare beneficiaries and the program, 
To determine the effects of the 
OIG recommends that CMS expand the price-substitution policy.  CMS did not 
price-substitution policy, we determined 
the difference between ASP-based  concur with the recommendation.  However, CMS stated that as additional data 
payment and AMP-based payment for  becomes available and as it continues to gain experience with the 
each drug with a price substitution.  We  price-substitution policy, it will consider further changes as necessary.  OIG 
then applied this difference to the 
recognizes that CMS, in setting policy for payment substitution, needs to 
Medicare utilization for each of these 
achieve an important balance between safeguarding access to drugs and 
drugs.  To account for a 3-quarter lag 
ensuring that Medicare and its beneficiaries do not overpay for drugs.  To 
between the reporting of pricing data 
and the application of price substitutions,  provide greater flexibility and achieve this continued balance, any future 
we used drug utilization data for the  expansion of the payment-substitution policy could contain a provision that 
fourth quarter of 2015 through the third  would prevent a price substitution when there are indications that the 
quarter of 2016 to calculate the savings 
substitution amount is below the provider acquisition costs.
based on 2015 ASP data.   
Full report can be found at http://oig.hhs.gov/oei/reports/oei-03-17-00360.asp   
BACKGROUND 
When Congress established average sales price (ASP) as the 
  Drug Pricing Terms  basis for Medicare Part B drug reimbursement, it also provided 
a mechanism for monitoring market prices and adjusting 
Manufacturers Average Sales Price  ASP-based payments in certain situations.  Specifically, the 
(ASP)  Social Security Act (the Act) mandates that the Office of 
In general, the manufacturers ASP  Inspector General (OIG) compare ASPs with average 
for a unit of drug that is sold is  manufacturer prices (AMPs).1  If OIG finds that the ASP for a 
defined as the manufacturers sales  drug exceeds the AMP by a certain percentage (currently 
of a drug to all purchasers in the 
5 percent), the Act directs the Secretary of Health and Human 
United States in a calendar quarter 
Services (after being notified by OIG) to substitute the payment 
divided by the total number of units 
amount with the lesser of the widely available market price 
of the drug sold by the manufacturer 
(if any) or 103 percent of the AMP.2, 3     
in that same quarter. 
Payments for Prescription Drugs Under Medicare 
Average Manufacturer Price (AMP) 
Part B 
In general, AMP is defined as the 
Medicare Part B covers a limited number of outpatient 
average price paid to the 
manufacturer for the drug in the  prescription drugs.  These drugs are usually administered in a 
United States by (1) wholesalers for  physicians office or other outpatient setting and include, for 
drugs distributed to retail community  example, drugs used to treat cancer.  To obtain reimbursement 
pharmacies and (2) retail community  for Part B drugs, health care providers submit claims to 
pharmacies that purchase drugs  Medicare contractors using Healthcare Common Procedure 
directly from the manufacturer.  Coding System (HCPCS) codes.  (Hereinafter in this report, we 
Wholesale Acquisition Cost (WAC)   refer to HCPCS codes as drugs.4)      
WAC is defined as the manufacturer's  CMS calculates the payment amount for these drugs using 
list price for a drug to wholesalers or 
information provided by manufacturers.  Certain 
direct purchasers.  It does not include 
manufacturers must provide CMS with the ASP and volume of 
discounts or rebates.  
sales for each of their national drug codes (NDCs) on a 
National Drug Code (NDC)  quarterly basis.5, 6  CMS then calculates an ASP-based payment 
An NDC is a code used to identify a  amount for the drug, which includes all of the NDCs associated 
drug based on its manufacturer,  with the drug.7  Under the ASP pricing methodology, the 
product, and package size.    Medicare reimbursement for most Part B drugs is equal to 
106 percent of the volume-weighted ASP for the drug.8  
Healthcare Common Procedure 
Coding System (HCPCS) Code  However, under sequestration legislation, the payment amount 
A HCPCS code is a standardized billing  for most drugs is reduced by 2 percent.9   
code that is used primarily to identify 
Quarterly reimbursement amounts are not based on current 
products, supplies, and other 
quarter data because there is a 2-quarter lag between the sales 
services.  A HCPCS code specifies the 
period for which ASPs are reported and the effective date of 
name and the amount of the drug 
the reimbursement amounts.  For example, manufacturers 
and may represent one or more 
ASPs from the first quarter of 2015 were used to establish 
NDCs. 
reimbursement amounts for the third quarter of 2015. 
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  1  
OEI-03-17-00360    Manufacturer Reporting of AMPs 
In addition to providing quarterly ASPs, certain manufacturers must provide CMS quarterly with the 
AMP for each of their NDCs.10, 11  The AMP is generally calculated as a weighted average of prices for all 
of a manufacturers package sizes of a drug and is reported for the lowest identifiable quantity of the 
drug, e.g., 1 milliliter, one tablet, one capsule.   
AMP-Based Price Substitutions 
Through regulation, CMS established the criteria under which it would implement a price substitution 
for a drug.  CMS may substitute 103 percent of the AMP for the ASP-based reimbursement amount 
when OIG identifies a drug that exceeds the 5-percent threshold in the 2 previous quarters or 3 of the 
previous 4 quarters.12  CMS implemented the AMP substitution policy in April 2013.  Because CMS 
believes that comparisons based on partial AMP data may not adequately reflect market trends, the 
agency will consider lowering reimbursement amounts only when corresponding AMP data is available 
for each of the NDCs used to determine the published reimbursement amount for a drug.13  To prevent 
the price-substitution policy from inadvertently raising Medicare reimbursement amounts, CMS does 
not substitute prices when the substituted amount is greater than the ASP-based payment amount 
calculated for the quarter in which the price substitution takes effect.14  CMS also does not substitute 
prices when a drug is identified by the Food and Drug Administration (FDA) as being in short supply.15  
Price substitutions take effect in the quarter after OIG shares the results of its most recent pricing 
comparison and remain in effect for one quarter.16   
Because of the 2-quarter lag between the ASP reporting period and the effective date of 
reimbursement amounts, and the additional quarter that is necessary for OIG to complete its pricing 
comparison, there is a 3-quarter lag between the ASP reporting period and the effective date of the 
price substitutions.  As shown in Exhibit 2, price substitutions that took effect in the fourth quarter of 
2015 were based on comparisons of ASPs and AMPs from the first quarter of 2015.   
Exhibit 2:  Timeline for AMP-Based Price Substitutions in 2015 
 Manufacturers collect ASPs and AMPs from the first quarter of 2015 for their drugs sold during that 
  First   quarter 
Quarter  
2015 
Manufacturers send ASPs and AMPs from the first quarter of 2015 to CMS by April 30, 2015 
  Second   CMS sends first quarter 2015 ASP and AMP data to OIG by end of June 2015 
Quarter  
2015 
  OIG identifies the drugs that meet the price-substitution criteria and provides them to CMS by  
August 15, 2015 
  Third   CMS publishes Part B drug reimbursement rates for the fourth quarter of 2015, including price 
Quarter  
substitution for drugs that met the criteria based on data from the first quarter of 2015  
2015 
 CMS uses AMP-based reimbursements for Part B drugs that met criteria based on data from the first 
  Fourth  quarter of 2015 
Quarter  
2015 
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  2  
OEI-03-17-00360    OIG Monitoring of ASPs and AMPs 
To comply with its statutory mandate, OIG has provided CMS with pricing comparisons since the 
January 2005 implementation of the ASP reimbursement methodology for Part B drugs.  OIG issued 
six annual public reports for the years prior to CMSs April 2013 implementation of the AMP 
price-substitution policy.  These reports estimated that Medicare and its beneficiaries would have 
saved $35 million if CMS implemented the AMP price substitutions.  OIGs 2013 annual report was the 
first to provide annual savings that were a direct result of CMSs price-substitution policy.  CMSs price 
substitutions based on 2013 and 2014 data saved Medicare and its beneficiaries an estimated 
 
$37 million.
RESULTS 
CMSs price-substitution policy saved Medicare and its beneficiaries 
$5.4 million over 1 year  
CMS initiated price substitutions for 13 drugs based on 2015 data.17  Price substitutions for these drugs 
saved Medicare and its beneficiaries $5.4 million over the 1-year period between the fourth quarter of 
2015 and the third quarter of 2016.  Exhibit 3 lists the 13 drugs, the quarter(s) during which the price 
substitution(s) occurred, and the savings.  
Exhibit 3:  Drugs With Price Substitutions Based on 2015 Data 
    Quarter(s) in Which Price Substitutions   
Occurred 
Drug  Description  Fourth  First  Second  Third  Savings 
Quarter  Quarter  Quarter  Quarter 
2015  2016  2016  2016 
       
J1110  Dihydroergotamine mesylt injection  $9,236 
       
J1450  Fluconazole  $154 
       
J1570  Ganciclovir sodium injection  $47,709 
J1740  Ibandronate sodium injection             $017 
       
J2150  Mannitol injection  $4,968 
       
J2675  Progesterone injection  $279 
       
J3415  Pyridoxine HCl injection  $10,620 
       
J7520  Sirolimus oral  $5,270,778 
       
J9178  Epirubicin HCl injection  $1,387 
       
J9200  Floxuridine injection  $19,874 
       
J9209  Mesna injection  $40,070 
       
Q0166  Granisetron HCl oral  $1,089 
       
Q0167  Dronabinol oral  $16,433 
             Total  $5,422,597 
Source:  OIG analysis of ASP and AMP data from 2015 
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  3  
OEI-03-17-00360    Expanding the price-substitution criteria could have generated up to 
$17 million in additional savings for Medicare and its beneficiaries   
CMS has maintained a cautious approach to price substitutions.  However, this cautious approach may 
restrict the Governments ability to limit potentially excessive payment amounts based on ASPs.  If CMS 
had expanded its price-substitution criteria to include certain other Part B drugs in 2015, Medicare and 
its beneficiaries could have saved up to an additional $17 million over 1 year. 
Millions could be saved by expanding the substitution criteria to include drugs that exceeded the 
5-percent threshold in a single quarter.  Nineteen drugs with complete AMP data exceeded this 
threshold in at least 1 quarter of 2015 but were not eligible for price substitution in that quarter 
because they did not meet CMSs duration criteria, i.e., did not exceed the threshold in the 2 previous 
quarters or 3 of the previous 4 quarters.18  If the 19 drugs had been eligible for price reductions on the 
basis of data from a single quarter only, Medicare and its beneficiaries could have saved up to an 
additional $10.5 million between the fourth quarter of 2015 and the third quarter of 2016.     
Previously, CMS has expressed concern that price substitutions based on results from a single quarter 
may represent 1 aberrant quarter of pricing rather than a market trend.19  However, price discrepancies 
for the majority of the 19 drugs do not appear to have resulted from isolated fluctuations.  According to 
2014 and 2015 data, 14 of these 19 drugs exceeded the 5-percent threshold more than once over the 
2-year period.20  Over the 2-year period, 7 of the 19 exceeded the threshold in 2 of the 8 quarters, and 
another 7 drugs exceeded the threshold three or more times in the 8 quarters.   
If CMS would prefer to employ a more cautious approach than substitution based on a single quarter of 
data, it could expand its price-substitution criteria to include drugs that exceed the 5-percent threshold 
in 2 of the previous 6 quarters.  Under this approach, 9 drugs would have been eligible for price 
substitutions.  Medicare and its beneficiaries could have saved an estimated $4.3 million on these 
9 drugs.   
CMS also could expand the price-substitution criteria by using a proxy for missing AMP values.  
Currently, CMS will consider lowering reimbursement amounts only when corresponding AMP data is 
available for each of the NDCs used to determine the published reimbursement amount for a drug.  We 
used wholesale acquisition costs (WACs) as the proxy for missing AMP values.  According to our analysis 
of 2015 data, WACs function as a conservative proxy for missing AMP values because at least 
94 percent of WACs were higher than or equal to AMPs each quarter.  WACs are commonly higher than 
AMPs.  Therefore, substituting WACs for AMPs affords a more conservative calculation because the 
difference between the ASP and the WAC would most likely be less than the difference between the 
ASP and the missing AMP.  We identified two drugs that would have met CMSs substitution criteria if 
WACs had been used in place of the missing AMP data.21  Between the fourth quarter of 2015 and third 
quarter of 2016, Medicare and its beneficiaries would have saved $6.4 million on these two drugs if the 
price-substitution criteria had been expanded to allow WACs to be used for missing AMP values.   
CONCLUSION AND RECOMMENDATION 
Under the current price-substitution policy, 13 drugs were subject to reimbursement reductions on the 
basis of data from 2015, saving Medicare and its beneficiaries $5.4 million between the fourth quarter 
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  4  
OEI-03-17-00360    of 2015 and the third quarter of 2016.  CMS could achieve even greater savings for Medicare and its 
beneficiaries by expanding its criteria for AMP-based price substitutions.   
OIG has previously recommended that CMS expand the price-substitution criteria.  CMS indicated that 
it does not concur with expanding the price-substitution policy and continues to believe that more 
experience with this policy is needed before it can be expanded.  CMS also expressed concern that 
expanding price-substitution criteria may impede physician and beneficiary access to drugs.  OIG agrees 
that access to prescription drugs should always be considered when contemplating pricing policies and 
supports current safeguards to prevent substitutions for drugs that are identified by FDA as being in 
short supply.  However, OIG continues to believe that CMS can achieve a better balance between 
safeguarding access to drugs and ensuring that Medicare and its beneficiaries do not overpay for drugs.  
To provide greater flexibility and achieve this continued balance, any future expansion of the 
payment-substitution policy could contain a provision that would prevent a price substitution when 
there are indications that the substitution amount would be below provider acquisition costs. 
Therefore, we continue to recommend that CMS: 
  Expand the price-substitution policy  
To more effectively limit excessive payment amounts based on ASPs and to generate greater 
savings for Medicare and its beneficiaries, CMS should consider broadening its 
price-substitution criteria to include at least some additional drugs.  A more expansive policy 
might include drugs with complete AMP data that exceed the 5-percent threshold in a single 
quarter.  However, CMS also could consider a more modest expansion of the policy that better 
captures drugs that repeatedly exceed the threshold.  For example, CMS could expand the 
criteria to include drugs with complete AMP data that exceed the 5-percent threshold in 2 of 
6 quarters.     
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE 
CMS did not concur with our recommendation.  However, CMS stated that as additional data becomes 
available and as it continues to gain experience with the price-substitution policy, it will consider 
further changes as necessary.  CMS believes the current policy safeguardswhich identify drugs that 
exceed the 5-percent threshold for 2 consecutive quarters or 3 of 4 quartersidentify situations in 
which AMP consistently exceeds ASP. 
OIG continues to believe that expanding the policy can achieve a balance between safeguarding access 
to drugs and ensuring that Medicare and its beneficiaries do not overpay for drugs.  Our examination of 
2015 data shows that if the policy had been expanded to include the 19 drugs that exceeded the 
5-percent threshold in a single quarter, up to an additional $10.5 million could have been saved by 
beneficiaries and the program.  The majority of the 19 drugs we identified for these potential savings 
exceeded the threshold multiple times over a 2-year period.  Expanding the policy to capture drugs that 
exceed the threshold in a single quarter could increase the savings to beneficiaries and the program 
and still ensure access to drugs.  
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  5  
OEI-03-17-00360    To help ensure that CMS has sufficient information for its consideration regarding the 
price-substitution policy, OIG will continue to provide CMS with the results from our quarterly pricing 
comparisons, along with annual reports on the impact of the price-substitution policy.  
For the full text of CMSs comments, see Appendix B.   
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  6  
OEI-03-17-00360    APPENDIX A:  METHODOLOGY 
Data Collection and Analysis  
We obtained NDC-level ASP data, AMP data, and WAC data for Part B drugs from CMS for 2015.  We 
also obtained ASP-based reimbursement amounts and Part B drug utilization for the quarters in which 
price substitutions occurred, i.e., the fourth quarter of 2015 through the third quarter of 2016.  In 
addition, we obtained the drugs that had price substitutions based on data from 2015.   
For each quarter of 2015, we calculated the volume-weighted AMP for drugs consistent with CMSs 
methodology for calculating volume-weighted ASPs.  We then compared the volume-weighted ASPs 
and AMPs and identified all drugs with ASPs that exceeded the AMPs by at least 5 percent.  We also 
identified drugs that exceeded the 5-percent threshold but did not meet CMSs duration criteria for 
price substitution, i.e., they did not exceed the threshold in the 2 previous quarters or 3 of the previous 
4 quarters.  In addition, we identified drugs with missing AMP values, i.e., drugs that had AMP data for 
only some of the NDCs that CMS uses to calculate the volume-weighted ASP needed to determine the 
published reimbursement amount.   
To calculate the savings associated with price substitutions or potential price substitutions that could 
be made by expanding the policy, we first reduced AMP-based and ASP-based reimbursement amounts 
(103 percent of the volume-weighted AMP and 106 percent of the volume-weighted ASP, respectively) 
by the 2-percent reduction required by sequestration legislation.  We then subtracted the AMP-based 
reimbursement amount from the ASP-based reimbursement amount for the quarter in which the price 
substitution occurred22 and multiplied the difference by the Part B utilization for each drug in the 
respective quarter that the price substitution occurred.  For drugs with missing AMP data, we followed 
the same steps to calculate savings, but we substituted the manufacturer-reported WAC in place of 
each missing AMP value. 
Limitations 
We did not verify the accuracy of manufacturer-reported ASP and AMP data, nor did we verify the 
underlying methodology used by manufacturers to calculate ASPs and AMPs.  We also did not verify the 
accuracy of CMSs calculations of Part B drug reimbursement amounts. 
Manufacturers are required to submit their quarterly ASP and AMP data to CMS within 30 days after 
the close of the quarter.  We did not determine whether manufacturers provided any updated data to 
CMS at a later date. 
Standards 
This study was conducted in accordance with the Quality Standards for Inspection and Evaluation 
issued by the Council of the Inspectors General on Integrity and Efficiency.  
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  7  
OEI-03-17-00360    APPENDIX B:  AGENCY COMMENTS 
   
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  8  
OEI-03-17-00360    ENDNOTES 
 
1 Section 1847A(d)(2)(B) of the Act. 
2 Section 1847A(d)(3) of the Act. 
3 Pursuant to  1847A(d)(3)(B)(ii) of the Act, the threshold percentage has been maintained at 5 percent. 
4 A HCPCS code for a drug defines the drug name and the amount of the drug represented by the HCPCS code but 
does not specify the manufacturer or package size. 
5 Section 1927(b)(3) of the Act. 
6 An NDC is a drug code that represents a specific manufacturer, product, and package size. 
7 Section 1847A(c) of the Act.  Certain types of sales are exempted from ASP, and ASP is net of any price 
concessions (with limited exceptions). 
8 Section 1847A(b)(1) of the Act.  Medicare beneficiaries are responsible for 20 percent of this amount in the form 
of coinsurance. 
9 Part B claims dated on or after April 1, 2013, incur a reduction in payment in accordance with the Budget 
Control Act of 2011 and the American Taxpayer Relief Act of 2012 (see CMS Medicare FFS Provider e-News, 
Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program Sequestration, March 8, 2013).  
Under this mandatory payment reduction, the payment rate for most Part B drugs is reduced by 2 percent.  This 
reduction does not apply to the coinsurance portion of the Medicare allowed amount for Part B drugs. 
10 Section 1927(b)(3) of the Act. 
11 Section 1927(k)(1) of the Act. 
12 42 CFR  414.904(d)(3). 
13 Ibid.  
14 Ibid.  
15 Ibid. 
16 Ibid. 
17 In the October 2015 ASP Pricing File available on CMSs website, CMS reported an AMP price substitution for 
code J1740.  However, the actual price that was provided in that file and used for reimbursement was the ASP 
plus 6 percent, not the substitution price of 103 percent of AMP.  Therefore, we did not calculate any savings for 
code J1740. 
18 These 19 drugs were not identified by FDA as being in short supply and did not have AMP-based substitution 
amounts that were greater than the ASP-based reimbursement amounts in the quarters during which the 
substitutions would have occurred.  One of these drugs did not have any allowed Part B utilization during the 
reviewed period; therefore, the estimated savings for this drug was $0. 
19 76 Fed. Reg. 73026, 73288 (Nov. 28, 2011). 
20 This analysis is based on pricing comparison results for the 2-year period between the first quarter of 2014 and 
the last quarter of 2015. 
21 WAC is defined in  1847A(c)(6)(B) of the Act.  The WAC is the manufacturers list price for the drug or 
biological to wholesalers or direct purchasers in the United States for the most recent month for which the 
information is available.   
22 AMP-based price substitutions based on data from the first through fourth quarters of 2015 were applied in the 
fourth quarter of 2015 through the third quarter of 2016, respectively. 
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  9  
OEI-03-17-00360    ACKNOWLEDGMENTS 
Conswelia McCourt served as the team leader for this study.  Office of Evaluation and Inspections staff 
who provided support include Joe Chiarenzelli, Althea Hosein, and Christine Moritz.  
This report was prepared under the direction of Linda Ragone, Regional Inspector General for 
Evaluation and Inspections in the Philadelphia regional office, and Edward Burley, Deputy Regional 
Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov. 
Medicare Part B Drug Payments:  Impact of Price Substitutions Based on 2015 Average Sales Prices  10  
OEI-03-17-00360