Updates for medication codes billed under the medical benefit

Effective for dates of service on and after August 3, 2022, the following updates for medication codes billed on medical claims will apply.

 

Please note, inclusion of a national drug code on your medical claim is necessary for claim processing of drugs billed with a not otherwise classified (NOC) code:

• Both the Healthcare Common Procedure Coding System (HCPCS) and National Drug Code (NDC) must be accurate and applicable to the medication requested.
• The manufacturer of the submitted NDC must participate in the Medicaid Drug Rebate Program.
• The submitted NDC must not be for a DESI 5 or 6 drug. (DESI 5 or 6 drugs are drugs that have been defined by the FDA as less than effective.)
• Participating manufacturers and DESI designations are updated quarterly and can be found at https://data.medicaid.gov/dataset/0ad65fe5-3ad3-5d79-a3f9-7893ded7963a/data.

 

Visit the Clinical Criteria website to search for specific Clinical Criteria.

 

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate or call Provider Services at
855-661-2028.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

KYBCBS-CD-005206-22