MedicaidBilling CodesHigh impact
Updates on Lupron Depot Injections for State Health Plan Members
BlueCross BlueShield of South Carolina·SC · Oncology, Endocrinology, Urology·Benefits and Eligibility
Effective date
Jan 1, 2026
We identified it
Aug 20, 2026
Summary
Effective January 1, 2026, Lupron Depot injections for State Health Plan members transitioned from pharmacy benefit coverage to medical benefit coverage. All claims must now be billed through the medical benefit instead of pharmacy, and prior authorization remains required and must be submitted through MBMNow before administering the medication.
Action Required
Immediately: Billing team must update all billing system configurations to route Lupron Depot (J9218) claims to the medical benefit instead of the pharmacy benefit for State Health Plan members. Update encounter templates and billing workflows to require prior authorization submission through MBMNow before any Lupron Depot administration. Train all staff on the new billing pathway. Verify prior authorization is obtained and documented before claims are submitted. Failure to bill through the medical benefit or obtain required prior authorization will result in claim denials.