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HighmarkCommercial · Billing Codes · Pharmacy · PA, NY, DE, WV · Oncology, Rheumatology, Endocrinology +1 moreHigh impact

Medical Injectable Drug Program Changes in the New Year

Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 25, 2026

Summary

Effective January 1, 2027, Highmark is adding 13 new drugs to its Medical Injectable Drug Program and adjusting reimbursement rates to align with average selling price (ASP) or average wholesale price (AWP) for drugs lacking an ASP. These drugs receive HCPCS codes and remain in the program once coded. Billing teams must update their systems to recognize these new HCPCS codes and apply the correct reimbursement methodology.

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What to do

by Dec 31, 2026 · 5 steps
01Billing team must update the billing system to recognize and process all 12 new HCPCS codes (J0897, Q5136, Q5157, Q5158, Q5159, Q5161, Q5162, Q5165, Q5166, Q5167, Q5171, Q5173) for Highmark plans.
02Configure reimbursement rules to apply ASP-based pricing for these drugs, or AWP pricing if ASP is unavailable.
03Verify that these codes are added to charge masters and fee schedules in the billing software.
04Test claims submission with sample transactions before the effective date.
05Update provider documentation and internal billing procedures to reflect the new drug program additions.
If missed: Failure to update coding systems may result in claim denials or incorrect reimbursement for injectable drug administrations.

Codes mentioned

J0897Q5136Q5157Q5158Q5159Q5161Q5162Q5165Q5166Q5167Q5171Q5173

Original notice

Medical Injectable Drug Program Changes in the New Year
providers.highmark.com · Always check the source before changing claims.
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Related changes

See all Highmark changes →
Medical Injectable Drug Program Changes in the New YearHighEffective Jan 1, 2027 · PharmacyTechnical Coding Alignment for Prior Auth Processing of Select MIDsMediumEffective Sep 1, 2026 · Prior AuthorizationBrowse every Highmark change in the policy list

Related policy hubs

Highmark policiesPA policy changesNY policy changesDE policy changesWV policy changesOncologyRheumatologyEndocrinologyInfectious DiseaseCode J0897Code Q5136Code Q5157Code Q5158Code Q5159Code Q5161Code Q5162Code Q5165Code Q5166Code Q5167Code Q5171Code Q5173

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