The WAC/AWP based on the National Drug Code (NDC) for the specific drug billed Method

Method 1

1. The WAC/AWP based on the National Drug Code (NDC) for the specific drug billed. Method 2

1. For a single-source drug, the WAC/AWP equals the WAC/AWP of the single product. 2. For a multi-source drug, the WAC/AWP is equal to the lesser of the median WAC/AWP of all the generic forms of the drug or the lowest brand name product WAC/AWP.

BCBST reserves the right to select the method used to calculate ASP/WAC/AWP and the source for ASP/WAC/AWP for infusion therapy, immunosuppressive, immune globulins, nebulizer, chemotherapy and other injectable drugs not published by Medicare Part B – Tennessee. Examples of sources for WAC/AWP include, but are not limited to First Data /Medispan, Redbook, and information provided by the drug manufacturer.

To determine eligibility and reimbursement for an injectable drug, BCBST reserves the right to request the name of the drug, National Drug Code (NDC), specific dosage administered

and number of units, based on specific code description. For items billed with an unlisted, miscellaneous, not otherwise classified HCPCS code, specific dosage administered should be reported in appropriate form and number of units.

Refer to Provider Contract Agreements for network percentages and specific sources for facilities, professional Providers, and Home Infusion Therapy Providers.

Billing Guidelines General

 When billing specific codes for drugs, the number of units billed should be based on the code description rather than the manufacturer’s packaging.

 Place of service should indicate where the medication is administered or instilled into external/implanted pump rather than where it is dispensed.

 Separate line items should not be billed for the HCPCS when the same therapeutic agent is administered on the same date of service. If different packages of the same therapeutic agent, with different national Drug Codes (NDCs), must be utilized to obtain the order dosage. Block 19 – Reserved For Local Use, section of the CMS-1500 or its equivalent should be utilized to report additional NDCs required.

 Saline and heparin, utilized for flushing and maintenance of infusion devices, are considered supplies included in professional services and home infusion therapy (HIT) per diems. These supplies are not eligible for separate reimbursement.

 Basic pre-packaged intravenous fluids utilized for IV hydration administered in the

Practitioner’s office and fluids (e.g., partial-fills, 50 /100 / 250 ml bottles/bags) utilized to mix or facilitate administration of therapeutic agents in all places of service are considered supplies and are not eligible for separate reimbursement.

 Medications billed with unlisted, miscellaneous, non-specific and Not Otherwise Classified (NOC) codes should be billed with a unit of one (1) and require submission of drug name, National Drug Code (NDC), and dosage administered in appropriate form as ordered by Practitioner. Failure to submit this information may result in delay of reimbursement.

Compounds

 Only off-the-shelf medications packaged as manufactured from a pharmaceutical company should be coded utilizing specific HCPCS Level II codes with the exception of some inhalation mixtures having assigned specific codes.

 Refer to Compound Drugs in this Manual section for guidelines on medications compounded from bulk powder or altered from the manufacturers’ packaging. Medication Wastage

 When necessary to discard a portion of a single dose vial (SDV), documentation of time, date, drug name, dosage administered, amount wasted and route of administration in the medical record is expected.

 Provider is responsible for using the most economical packaging of medication to achieve the required dosage with the least amount of medication wastage necessary.

 Wastage is not to be billed for medications available in multi-dose vials (MDV) and is not reimbursable.

 The NDC of the SDV requiring wastage should be submitted in Block 24 – Supplemental Information, section of the CMS-1500 or its electronic equivalent. Refer to Section VI. Billing and Reimbursement in this Manual for additional guidance.

 Instances of medication wastage from a SDV should be submitted on a single line item with the –JW modifier appended to the appropriate HCPCS Level II code. See General Guidelines section for reporting units of therapeutic agents with specific codes and for therapeutic agents billed with unlisted, miscellaneous, non- specific and Not Otherwise Classified (NOC) codes.

 The number of units billed for the SDV with specific HCPCS codes with the – JW modifier is inclusive of both the administered + discarded amounts.

 The number of units should be reported as one (1) for unlisted, miscellaneous, non-specific and Not Otherwise Classified (NOC) codes billed with the JW modifier appended. The “dosage administered” amount reported in Block 24 – Supplemental Information section of the CMS-1500 or its electronic equivalent should be inclusive of both the administered plus discarded amounts. The specific amounts administered and discarded should be reported in Block 19 - Reserved For Local Use section of the CMS-1500 or its electronic equivalent.

c. Preventive Vaccines Administered by a Pharmacist Claim Form

Preventive vaccines administered by a Licensed Pharmacist and covered under thMember’s medical plan must be billed on a Professional claim form. Only those vaccines actually

administered by the Pharmacist are to be billed. Vaccines administered in the pharmacy quick care clinic or by a subcontracted health care Provider (i.e. “flu clinics”) are not to be billed under these provisions.

Block 24b - Place of Service

The place of service (POS) should represent where the service is provided. Block 24a - From and To Date(s) of Service

Enter the month, day and year for each vaccine and administration service provided. Block 24d - Codes and Modifiers

Vaccines must be billed using the most appropriate CPT®_{/HCPCS code in effect for the date} of service.

Block 24g – Days or Units

To report units for medications, the units must be billed in accordance with the CPT®_{/HCPCS definition in effect for the date of service and the Practitioner’s order.} General Billing Guidelines

 BCBST reserves the right to request the name of the drug, National Drug Code (NDC), dosage per the Practitioner’s order and quantity.

 Updates to the maximum allowable for existing codes will be made in accordance with the BCBST Reimbursement Policy for Immune Globulins, Vaccines and Toxoids.

 Due to frequent changes in AWP, BCBST reserves the right to update the maximum allowable amount without prior notification.

 Updates to the maximum allowable may result in increases and decreases in fees.

 Refer to Section XIX. Pharmacy in this Manual for additional guidelines. d. Specialty Pharmacy Medications

Claim Form

Specialty pharmacy medications covered under the Member’s medical plan must be billed on a Professional claim form. Self-administered specialty pharmacy medications must be billed through the Member’s pharmacy benefits manager.

Block 24b - Place of Service

The place of service (POS) should represent where the service is provided. Block 24a - From and To Date(s) of Service

Enter the month, day and year for each medication provided.

Block 24d - Codes and Modifiers

Medications must be billed using the most appropriate HCPCS code in effect for the date of service.

In the event there is not a specific HCPCS code for the medication, the most appropriate unlisted code (e.g., J3490, J7599, J9999) in effect for the date of service may be used. Unlisted, miscellaneous, non-specific and Not Otherwise Classified (NOC) codes should only be used when a more specific CPT® _{or HCPCS code is not available or appropriate.} Medications billed with unlisted, miscellaneous, non-specific and Not Otherwise Classified (NOC) codes must be billed with the name of the drug, National Drug Code (NDC), dosage per the Practitioner’s order and quantity.

Block 24g – Days or Units

To report units for medications, the units must be billed in accordance with the HCPCS definition in effect for the date of service and the Practitioner’s order.

General Billing Guidelines

 BCBST reserves the right to request the name of the drug, National Drug Code (NDC), dosage per the Practitioner’s order and quantity.

 Updates to the maximum allowables for existing codes will be made in accordance with the BCBST Reimbursement Policy for Infusion Therapy, Immunosuppressive, Nebulizer, Chemotherapy and Other Injectable Drugs.

 Due to frequent changes in ASP/WAC/AWP, BCBST reserves the right to update the maximum allowable amount without prior notification.

 Updates to the maximum allowables may result in increases and decreases in fees.

 Reimbursement for medications is limited to that amount actually prescribed and administered to the Member.

 Provider is responsible for using the most economical packaging of medication to achieve the required dosage for the Member with the least amount of medication wastage.

 Refer to Section XIX. Pharmacy in this Manual for self-administered specialty pharmacy medications as defined by BCBST covered under the Member’s medical benefits plan.

e. Compound Drugs

Eligible compound drugs must be billed with the most appropriate HCPCS Level II

unclassified/not otherwise classified code and contain at least one legend drug with a valid National Drug Code (NDC) and billed on a Professional claim form.

BCBST maximum allowable is $0.00 for the following:  Non-legend drugs

 Compounding and/or dispensing fees (May be considered for some lines of business – see following related Compound Services Policy)

 Diluents, solvents, or other ingredients utilized to mix, combine, or alter legend drug component(s)

The maximum allowable for compound drugs is determined from individual claim review and may vary by claim based on supplemental information provided with the claim or related claims. Supplemental information includes, but is not limited to:

 The name(s) of the drug component(s), NDC of legend drug component(s), and specific dosage of legend component(s) administered, instilled, inserted, or implanted.

The maximum allowable for eligible compound drugs for professional Providers is based on a percentage of Wholesale Acquisition Cost (WAC) or Average Wholesale Price (AWP) based on the Provider Agreement according to one of the following methods:

Method 1