Medication claims

Medication claims

Claims for medications provided in your office should be submitted either to us as a medical claim or to our pharmacy benefits manager (PBM) as follows:

Services provided

To be reimbursed directly for medications provided during a visit/stay

Ambulatory surgery center (ASC)

Include in medical claim

Emergency room

Include in medical claim

Home health

Include in medical claim

Hospital or other inpatient setting

Include in medical claim

Medical or dental provider/clinic

  • Include in medical claim if covered under medical benefits
  • Submit claim to TransactRx if covered under Rx benefits
  • Learn more about determining which medications are covered under medical benefits

Pharmacy

Pharmacy submits claim through PBM

Skilled nursing facility (SNF)

Include in medical claim

Urgent care

Include in medical claim

Vaccines

  • Covered vaccines are usually eligible under medical benefits and can be included in the medical claim (for commercial and Medicare) except those that CMS has designated as Medicare Part D for Medicare patients
  • For Washington members: Vaccines provided under the Washington Universal Vaccine Program should be billed to the health plan as directed by the program

Infusion medications

  • Certain infusion medications are subject to the Site of Care Program (dru408) medication policy (PDF)
  • For other infusion medications, each medication policy states whether the drug is considered self-administered:
    • Self-administered medications are generally covered by the patient's pharmacy benefit
    • Claims for those that are considered non-self-administered should be submitted as a medical claim

NDC on medical drug claims

National Drug Codes (NDCs) must be included on all medical drug claims with a HCPCS code that starts with "J". Claims billed with a J code that do not have NDC information will be rejected with a request to complete the additional claim fields. This requirement applies to drugs administered in an:

  • Outpatient facility setting
  • Office by a physician or other health care professional

The 11-digit NDC number must be accompanied by the basis of measurement (UN, ML, etc.) and the NDC drug units. The claim should also include the corresponding HCPCS and CPT codes and the units administered for each code.

The 11-digit NDC number is in a 5-4-2-digit format, NNNNN-NNNN-NN, that is assigned to each drug product approved by the Food and Drug Administration (FDA). The NDC is usually found on the drug label or outer packaging. The number on the packaging may be less than 11 digits. An asterisk may appear as a placeholder for any leading zeros. The label also displays information about the NDC unit of measure for that drug. The three segments in the number indicate the following:

  • First segment– Identifies the company that manufactures or distributes the drug (assigned by the FDA)
  • Second segment– Identifies the product, its specific strength, dosage form and formulation of a drug (assigned by the drug manufacturer)
  • Third segment– Identifies the package size and type (assigned by the drug manufacturer)

You must enter the NDC on your claim in the 11-digit billing format with no spaces, hyphens or other characters. If the NDC on the package label is less than 11 digits, you must add a leading zero to the appropriate segment to create a 5-4-2 configuration. See the examples below:

Label configuration

Add leading zero, remove hyphens

4-4-2 (xxxx-xxxx-xx)

0xxxxxxxxxx

5-3-2 (xxxxx-xxx-xx)

xxxxx0xxxxx

5-4-1 (xxxxx-xxxx-x)

xxxxxxxxx0x

Unit of measurement requirements: The unit of measurement codes are also required to be submitted. Please use these codes for all claim forms:

  • F2 – International unit (products described as IU/vial or micrograms)
  • ML – Milliliter (e.g., liquid, solution or suspension)
  • UN – Unit (e.g., powder for injection (needs to be reconstituted), pellet, kit, patch, tablet, device)
  • ME – Milligram (e.g., drugs where the units, if converted to grams, would have too many decimal places and would not be accepted on the claim submittal)
  • GR – Gram (e.g., ointments, creams, inhalers or bulk powder in a jar)