Medicaid Update: Pharmacy Services Changes and Related Billing Guidelines and Reminders

November 11, 2020

This is an important notice regarding an upcoming change and related billing guidelines and reminders for pharmacy providers who have been submitting Blue Cross Community Health Plans^SM (BCCHP^SM) member claims to Blue Cross and Blue Shield of Illinois (BCBSIL) for medical drugs that are considered medical in nature.

What’s changing and why?
Effective Dec. 1, 2020, pharmacy providers may no longer submit BCCHP member claims to BCBSIL for any medical drugs that are considered medical in nature, or those drugs not listed on the Illinois Department of Health and Family Services (HFS) Medicaid Preferred Drug List (PDL) . For medical drugs considered medical in nature and not listed on the HFS PDL, BCCHP member claims must be submitted to BCBSIL by a medical provider [e.g., Physician, Advanced Nurse Practitioner (APN), Encounter Clinic, etc.]. This change is pursuant to the HFS provider notice, issued Dec. 19, 2019, titled, January 1, 2020 Requirements for Ordering/Referring/Prescribing Provider Enrollment and Managed Care Plan Adoption of HFS Preferred Drug List . As referenced in the HFS notice, as of Jan. 1, 2020, all Managed Care Organizations (MCOs) are required to follow the HFS PDL. Services listed on the HFS PDL will be dispensed by approved retail pharmacy providers at Point of Sale (POS). 

Additional Information, Billing Guidelines and Reminders
The additional information, guidelines and reminders below are included for reference purposes to assist you with transitioning related to the change referenced above, as well as to help support proper submission of other pharmacy services claims for our BCCHP members.

Pharmacy Services
Pharmacy providers must be registered in the HFS IMPACT system with provider type of 060 (Pharmacy) and may bill services that fall under the following Category of Service (COS) code types:

• 040 Pharmacy Services [Drug and Over the Counter (OTC)]
• 041 Medical Equipment/Prosthetic devices
• 048 Medical Supplies

The Illinois Medicaid program covers prescription drugs, as well as some OTC products made by manufacturers that have a signed rebate agreement with the Centers for Medicare & Medicaid Services (CMS). Services available at approved retail pharmacy providers at POS are mandated via the HFS PDL .

Each MCO has a pharmacy benefit manager (PBM) in place for POS prescriptions filled at the retail pharmacy. These PBMs manage the retail point of sale claim process for pharmacy providers. The POS claims are handled via these vendor relations for each MCO. The PBM for our BCCHP members is Prime Therapeutics.

In addition to specific POS services that must be handled by the PBM, there are some supplies per HFS guidelines that must be billed through the MCO’s PBM. A list of Durable Medical Equipment (DME) supplies that must be billed through the pharmacy billing system using a National Drug Code (NDC)  is available on the HFS website  – it includes examples of Healthcare Common Procedure Coding System (HCPCS) codes and descriptions.

Pharmacy providers registered with HFS with the following COS code types or specialties in the IMPACT file may bill DME supplies to BCBSIL for BCCHP members via the medical claim process: 

• 041 – Medical Equipment/Prosthetic Devices
• 048 – Medical Supplies

The charges must be submitted via an electronic Professional claim (837P transaction) or on a paper CMS-1500 claim form. For example, HFS pharmacy provider type 060 may bill for certain medical equipment, if approved for the following categories of service (COS 041 and 048) on the IMPACT file. Some of the medical services pharmacies (PT 060) can bill to BCBSIL for BCCHP members include, but are not limited to, the following:

• Food Thickeners – B4100
• Parenteral Nutrition Administration Kit – B4224
• External Insulin Infusion Pumps – A4230, A4231
• Gastro/JeJunoTube – B4088
• Enteral Feeding Supply Kit – B4035

Infusion Therapy Services
Infusion therapy equipment and supplies, such as ambulatory infusion, stationary infusion and enteral nutrition pumps all qualify as DME services the pharmacy can bill under the medical plan. All supplies needed to maintain intravenous (IV) access are included in the infusion pump codes, such as: alcohol pads, betadine swabs, sharp containers, sterile gloves, dressing change kits, flushing syringes, vial adapters, extension sets, IV start kit, tape, IV cannulas (peripheral line), needleless system supplies, needles, cassette with tubing, TPN bag, administration set with filter, metered delivery tubing, etc., and cannot be billed separately. The maximum allowable rate for each code is a flat rate regardless of number of medications or amount of supplies needed.

HFS allows the following supplies to be billed separately:

• A thermometer
• One box of 100 non-sterile gloves per month
• Non-coring Huber-like needles

Refer to the Illinois HFS DME fee schedule  for the complete listing of covered codes that can be submitted on the BCCHP medical claim platforms.

Important Note: HFS Provider Type 060, Pharmacies, cannot bill IV drug codes to the medical plan.
Below are some examples of common IV drugs that cannot be billed in Illinois Medicaid specifically by HFS pharmacy provider type 060 to BCBSIL for BCCHP members. 

Specialty pharmacy providers cannot submit claims via the medical plans for Illinois Medicaid for specialty drugs. HFS does not have a provider type that is defined as a specialty pharmacy or IV Infusion Provider types in Illinois Medicaid at this time that allows for reimbursement under the medical benefit. 

Providers must be contracted with both BCBSIL (as BCCHP participating providers) and Prime Therapeutics in order to bill pharmacy services for Illinois Medicaid members. Some additional prior authorizations may be required for services from out-of-network providers. Email our Government Programs Provider Relations team (govproviders@bcbsil.com) if you have questions related to contracting or prior authorization.

This material is for educational purposes only and is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials.

The material presented here is for informational purposes only and is not intended to be medical advice. Health care providers are instructed to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.

Please note that checking eligibility and benefits or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, contact the number on the member’s ID card.

Trademarks are the property of their respective owners.

The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions.

Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSIL contracts with Prime Therapeutics (Prime) to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime.