EmblemHealth reimburses for drugs furnished by participating practitioners to their patients based on the acquisition cost to the practitioner of the drug dose provided to the patient. Practitioners must, and are expected to, maintain auditable records of, and limit claim amounts to, the acquisition cost of the drug dose dispensed.
Practitioners can bill for medications dispensed to a patient via the medical claim format. Submit using an appropriate Healthcare Common Procedure Coding System (HCPCS) code and corresponding National Drug Code (NDC) when billing for a medication for which you have dispensed. If a specific HCPCS code has not been assigned for an oral medication, the following codes may be utilized:
- “J8999” – Rx Drug Oral Chemotherapy
- “J8499” – Rx Drug Oral Non-Chemotherapy
Practitioners may not submit an office visit claim for the sole purpose of dispensing a drug that the member can obtain at an EmblemHealth participating pharmacy.
JP# 56547 10/22