CommercialCoverageHigh impact
Changes in coverage for HCPCS drug codes
Blue Cross Blue Shield of Rhode Island·RI · Rheumatology, Infectious Disease, Neurology +3 more·Physician / Facility
Effective date
Dec 1, 2018
We identified it
Jun 20, 2026
Summary
Effective December 1, 2018, multiple HCPCS drug codes will no longer be covered under the medical benefit for Commercial products and must be billed through the member's pharmacy benefit instead. These are self-administered drugs that are moving from medical to pharmacy coverage.
Action Required
By December 1, 2018: Billing team must stop billing the listed HCPCS drug codes (J0717, J1324, J1438, J1559, J1595, J1744, J1830, J2170, J2941, J7639, J7682, J7686, Q3026, Q3027, Q3028, Q4074) to Commercial medical benefits. Update billing system to redirect these claims to pharmacy benefits. Inform providers that these self-administered drugs are now pharmacy-only for Commercial plans. Claims billed to medical benefit will be denied.