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CareSourceMedicaid · Coverage · Pharmacy · OH · Pharmacy, Pediatrics, Allergy & Immunology +2 moreHigh impact

[Ohio] Beyfortus Drug Billing Update

Act
by May 1, 2025
Effective date
May 1, 2025
Identified
May 9, 2026

Summary

Effective May 1, 2025, Ohio Medicaid is discontinuing coverage of Beyfortus (nirsevimab-alip) drug codes 90380 and 90381 through CareSource. VFC-enrolled providers should continue using the VFC program; non-VFC providers must transition to billing Beyfortus through Gainwell SPBM pharmacy. The administration code 96372 remains billable to CareSource for all providers.

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What to do

by May 1, 2025 · 7 steps
01Billing team must implement the following changes.
02VFC-enrolled providers: Continue requesting Beyfortus through the VFC program and submit only CPT 96372 (administration) to CareSource.
03Non-VFC providers: Stop submitting CPT 90380 and 90381 to CareSource and instead submit these drug codes to Gainwell SPBM (spbm.medicaid.ohio.gov), while continuing to submit CPT 96372 (administration) to CareSource.
04Update billing software to reject or route CPT 90380 and 90381 submissions to CareSource for Ohio Medicaid claims.
05Verify provider VFC enrollment status in system to ensure correct billing pathway.
06Failure to transition will result in claim denials for Beyfortus drug administration after May 1, 2025.
07Contact CareSource Provider Services at 1-800-488-0134 for questions.

Codes mentioned

903809038196372

Original notice

[Ohio] Beyfortus Drug Billing Update
caresource.com · Always check the source before changing claims.
View original ↗

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Related policy hubs

CareSource policiesOH policy changesPharmacyPediatricsAllergy & ImmunologyFamily MedicineGeneral PracticeCode 90380Code 90381Code 96372

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