Reimbursement Update for High-Cost Clinician-Administered Drugs (HCCADs)

Effective June 2, 2025, there will be a change in reimbursement for the following High-Cost
Clinician-Administered Drugs (HCCAD):

· ABECMA
· BREYANZI
· CARVYKTI
· CASGEVY
· ELEVIDYS
· HEMGENIX
· KYMRIAH
· LYFGENIA
· ROCTAVIAN
· SKYSONA
· TECARTUS
· YESCARTA
· ZOLGENSMA
· ZYNTEGLO

Reimbursement Policy Update

Hospitals must submit claims for these HCCADs separately as outpatient claims on a UB04. These drugs will no longer be reimbursed under the All-Patient Refined Diagnosis Related Group (APR-DRG) payment system. Instead, reimbursement will be made as direct payments based on the lesser of:

1. The Texas Medicaid Fee-For-Service (FFS) rate, or
2. The actual acquisition cost, as documented by an invoice.

Billing Requirements

To ensure proper reimbursement, hospitals must:

• Submit a separate outpatient claim on a UB04 for the HCCAD, separate from any institutional/facility claim for other hospital services provided on the same date.
• Include the following details in the claim:
  • NDC Qualifier: N4
  • 11-digit National Drug Code (NDC) and corresponding HCPCS code
  • Number of units administered
  • NDC unit of measurement (F2, GR, ML, UN, or ME)
• Use the date of drug administration as the date of service on the claim.
• Submit an invoice reflecting the actual acquisition cost of the drug.

Note: Drugs administered during an inpatient setting do not qualify for 340B.

Action:

Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6294. You can also contact your Provider Relations Representative directly.

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