National Drug Code (NDC) Pricing Paves the Way for Related Initiatives

October 14, 2013

NDC pricing will be implemented by Blue Cross and Blue Shield of New Mexico (BCBSNM) as of Nov. 1, 2013, for drugs billed under the medical benefit on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims. As of the Nov. 1, 2013 NDC pricing effective date, professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims for drugs must include NDC data in order to be accepted for processing by BCBSNM. If NDC data is not included as required by BCBSNM, your claim will be returned to you.

Use Generics, See Results
Making the transition to using NDCs on your claims may seem challenging, but it can also have its rewards. HCPCS/ Current Procedural Terminology (CPT®) codes used for billing medications under the medical benefit represent a broad therapeutic class or dose. The lack of specificity for HCPCS/CPT codes does not allow the identification of the specific product used. When you bill with NDCs in addition to including the appropriate HCPCS/CPT information, BCBSNM can identify and reimburse your office, in most instances, for the individual medication that was prescribed (instead of for a range of NDCs within HCPCS/CPT codes). Generically available or multiple source drugs will be reimbursed at a set competitive market rate. Providers will have the opportunity to maximize their reimbursement by using lower cost generic drugs.

Introducing Our Select Medication List
NDC pricing also paves the way for other initiatives, such as our new Select Medication List, which will be developed in stages to add specific drugs within particular classes or categories, based on safety and cost effectiveness. Currently, there are two medications on the Select Medication List – Synvisc-One® and Euflexxa®. These are injections from the viscosupplementation class and are used primarily for osteoarthritis knee pain relief. Choosing a drug from the Select Medication List and billing for it with the appropriate NDC will result in a higher reimbursement rate than the rate applied for other non-listed drugs in the same class.

Reimbursement for select medications is updated monthly, according to normal NDC reimbursement update processes. Increased reimbursement is limited to the medications on the Select Medication List. BCBSNM will be adding medications to the Select Medication List in the future; however, details regarding specific medications and timelines have not been finalized.

NDC Billing Resources
An NDC billing tutorial, NDC Units Calculator Tool and the NDC reimbursement fee schedule are available to registered providers on our secure Blue Access for ProvidersSM site. For quick reference purposes, view the NDC Billing Guidelines and answers to Frequently Asked Questions (FAQs).

CPT copyright 2012 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Trademarks referenced above are the property of their respective owners.

The listing of any particular drug or classification of drugs is not a guarantee of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, terms, conditions, limitations and exclusions set forth in the member’s policy or benefits document. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.

Synvisc-One is a registered trademark of Genzyme Corporation. Euflexxa is a registered trademark of Ferring Pharmaceuticals Inc. Genzyme Corporation and Ferring Pharmaceuticals are independent third party vendors and are solely responsible for the products and services they provide. The mention of a specific product or vendor is not an endorsement by BCBSNM, and BCBSNM makes no representations or endorsements regarding any of the vendors listed here. If you have any questions or concerns about the products or services they offer, you should contact the vendor(s) directly.

View all Provider News and Updates