MedicaidBilling CodesHigh impact
Medicaid provider update: High-cost Medicaid drug billing
UPMC Health Plan·Oncology, Hematology·Reimbursement
We identified it
Jun 20, 2026
Summary
UPMC for You and UPMC Community HealthChoices updated their Medicaid billing requirements for high-cost drugs, requiring specific NDC codes, separate claim lines for drug administration, and special handling for 340B drugs with UD modifiers. New restrictions apply to Cell and Gene Therapy treatments like Lyfgenia and Casgevy.
Action Required
Immediately: Billing team must update Medicaid drug billing procedures to include accurate NDC codes and units dispensed with corresponding J-codes on single claim lines. Bill drug administration separately from the drug itself. Add UD modifier for 340B-purchased drugs but exclude UD modifier for non-340B drugs. For Cell and Gene Therapies (Lyfgenia, Casgevy), verify provider registration with CIBMTR and use non-340B inventory for Medicaid patients. Update billing system edits to enforce these requirements or face claim denials and rebate program non-compliance.