Provider Alert! Maximum Allowable Update for Non-Risk Based Drugs Billed With ‘Unclassified’ Procedure Codes

Provider Alert!

Provider Alert! Maximum Allowable Update for Non-Risk Based Drugs Billed With ‘Unclassified’ Procedure Codes

Date: June 12, 2024

Attention: All Providers

Call to action: The Texas Health and Human Services Commission (HHSC) would like to disclose the maximum allowable reimbursement for Non-Risk drugs currently payable under an ‘Unclassified’ procedure code as referenced in the National Drug Code to Healthcare Common Procedure Coding System (NDC to HCPCS) crosswalk.

How this impacts providers: HHSC bases the pricing for an outpatient medical claim for an ‘Unclassified’ procedure code on the lesser of the manufacturer’s suggested retail price minus 18% or Average Wholesale Price (AWP) minus 10.5%. Currently, two Non-Risk drugs are billed with the ‘Unclassified’ procedure code. The effective date and current maximum allowable reimbursement rate for Skysona and Zynteglo are in the table below.

NDCDrug NameEffective DateTerm DateDrug TypeCodeMax Rate
73554211101SKYSONA INFUSION BAG-CASSETTE7/1/202312/31/9999CADJ3590$3,222,000
73554311101ZYNTEGLO INFUSION BAG-CASSETTE7/1/202312/31/9999CADJ3590$3,007,200

The qualified treatment center must send the prescription to the manufacturer-authorized specialty pharmacy. The pharmacy will process the claim for the drug through medical benefits using the ‘Unclassified’ procedure code.

As a reminder, HHSC limits Non-Risk payments to the actual amounts paid to providers for the drug’s ingredient cost (up to the fee-for-service reimbursement amount). TCHP requires the facility to submit an invoice.

Next step for Providers: Prescribers should share this communication with their staff. Provider must submit documentation (such as office chart notes, lab results, other pertinent clinical information, etc.) supporting that the member has met all appropriate criteria for medication approval.

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