National Drug Code (NDC) Pricing Paves the Way for Select Medication List

August 28, 2013

NDC pricing was implemented by BCBSIL as of June 1, 2013, for drugs billed under the medical benefit on professional/ancillary electronic (837P) and paper (CMS-1500) claims. As of the June 1, 2013, NDC pricing effective date, professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims for drugs must include NDC data in order to be accepted for processing by BCBSIL. If NDC data is not included as required by BCBSIL, your claim will be returned to you. 

Making the transition to using NDCs on your claims may seem challenging, but it can also have its rewards. When you bill with NDCs, BCBSIL can identify and reimburse your office, in most instances, for the individual medication that was prescribed (instead of for a range of NDCs within HCPCS/CPT codes). With this capability in mind, we’re introducing our new Select Medication List, which will be developed in stages to add specific drugs within particular classes or categories, based on safety and cost effectiveness. 

Currently, there are two medications on the Select Medication List – Synvisc-One® and Euflexxa®. These are injections from the viscosupplementation class and are used primarily for osteoarthritis knee pain relief. Choosing a drug from the Select Medication List and billing for it with the appropriate NDC will result in a higher reimbursement rate than the rate applied for other, non-listed drugs in the same class. 

Reimbursement for select medications is updated monthly, according to normal NDC reimbursement update processes. Increased reimbursement is limited to the medications on the Select Medication List. BCBSIL will be adding medications to the Select Medication List in the future; however, details regarding specific medications and timelines have not been finalized. 

Additional information on the Select Medication List and other NDC pricing-related initiatives will be published in the Blue Review. For quick reference purposes, view the NDC Billing Guidelines  and answers to Frequently Asked Questions.  A link to an NDC Billing Tutorial is also available to BCBSIL contracted providers in the Claims and Eligibility/Claim Submission section, under Related Resources.* 

*When clicking on the tutorial link in the Claims and Eligibility/Claim Submission section of our Provider website, you may be redirected to the Secure Content page. Follow instructions to proceed, and then look for the NDC Billing Tutorial link in the Related Resources. 

Trademarks referenced above are the property of their respective owners. 

The listing of any particular drug or classification of drugs is not a guarantee of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, terms, conditions, limitations and exclusions set forth in the member’s policy or benefits document. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider. 

Synvisc-One is a registered trademark of Genzyme Corporation. Euflexxa is a registered trademark of Ferring Pharmaceuticals Inc. Genzyme Corporation and Ferring Pharmaceuticals are independent third party vendors and are solely responsible for the products and services they provide. The mention of a specific product or vendor is not an endorsement by BCBSIL, and BCBSIL makes no representations or endorsements regarding any of the vendors listed here. If you have any questions or concerns about the products or services they offer, you should contact the vendor(s) directly.