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HighmarkAll Plans · Reimbursement · Pharmacy · NY · Pharmacy, Oncology, Rheumatology +2 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 without an ASP. Billing teams must update their systems to recognize the new HCPCS codes and apply the corrected reimbursement methodology for these injectable medications.

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What to do

by Dec 31, 2026 · 5 steps
01Billing team must update billing system software to recognize and process the 12 new HCPCS codes (Q5136, Q5157, Q5158, Q5159, Q5161, Q5162, Q5165, Q5166, Q5167, Q5171, Q5173) and the updated J0897 code.
02Configure reimbursement fee schedules to apply ASP-based pricing where available; use AWP for drugs lacking an ASP valuation.
03Update claim submission logic to ensure these drugs remain billable once assigned a HCPCS code.
04Verify Availity Essentials access and download the detailed MID Program Changes document from the Communications Hub under Resources to confirm drug-specific pricing and any additional billing guidance.
05Train billing and coding staff on the new codes and pricing methodology.
If missed: Failure to implement these changes will result in claim denials or payment at incorrect rates beginning January 1, 2027.

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 policiesNY policy changesPharmacyOncologyRheumatologyEndocrinologyInfectious DiseaseCode J0897Code Q5136Code Q5157Code Q5158Code Q5159Code Q5161Code Q5162Code Q5165Code Q5166Code Q5167Code Q5171Code Q5173

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