CurrentColorado Rocky Mountain Health PlansPolicy CS2026D0990AA

Denied Drug Codes - Pharmacy Benefit Drugs (for Arizona Only)

Denial of reimbursement for specific biologic/high-cost specialty drugs billed on medical professional (CMS-1500) and outpatient facility (UB-04) claims for UnitedHealthcare Community Plan of Arizona members; these must be billed under the outpatient pharmacy benefit and applies only to Arizona.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDenied Drug Codes - Pharmacy Benefit Drugs (for Arizona Only)

Policy CodePolicy CS2026D0990AA

Change TypeCoding update — replaced miscellaneous codes with J3404

Effective DateApr 1, 2026

Next Review Date

Key ActionDo not bill listed specialty biologic drugs on medical (CMS-1500) or outpatient facility (UB-04) claims; submit under the outpatient pharmacy benefit.

SourceLink

POLICY UPDATE CHANGES

Updated list of applicable HCPCS codes for Papzimeos to reflect quarterly edits and replaced C9399, J3490, and J3590 with J3404.

1state this policy applies to

multipleHCPCS/J/Q codes listed as denied on medical/UB claims

CMS-1500 & UB-04claim forms covered

04/01/2026policy effective date

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Denial Criteria

Denial criteria

Denial applies when ALL of the following are met:

The service is billed on a medical professional (CMS-1500) or outpatient facility (UB-04) claim (or their electronic equivalents).

The drug/service is one of the specialty biologic/high-cost injectable medications identified by HCPCS in this policy.

The drug is billed on the medical/UB claim rather than through the outpatient pharmacy benefit as required by AHCCCS direction.

Applicable HCPCS / J / Q Codes

Not covered HCPCS codesHCPCSNot Covered

J0180	Injection, agalsidase beta, 1 mg
J0221	Injection, alglucosidase alfa (Lumizyme), 10 mg
J0598	Injection, C1 esterase inhibitor (human), Cinryze, 10 units
J1411	Injection, etranacogene dezaparvovec-drlb, per therapeutic dose
Q2055	Idecabtagene vicleucel (Abecma), per therapeutic dose
J3404	Injection, zopapogene imadenovec-drba suspension, per therapeutic dose

Miscellaneous code rule (inv-03: Drugs submitted with J3490/J3590/C9399)

RuleDrugs listed without their own assigned J- or Q-code that are submitted with miscellaneous HCPCS codes J3490, J3590, or C9399 will not be reimbursable on professional (CMS-1500) or UB-04 claims.

ScopeApplies to injectable/high-cost specialty drugs identified in the Coverage Rationale for UnitedHealthcare Community Plan of Arizona.

Claim forms affectedCMS-1500 (professional) and UB-04 (outpatient facility) claims — and their electronic equivalents.

Payer alignmentAHCCCS requires biologic/high-cost specialty drugs in its Catastrophic Reinsurance Program be reimbursed on pharmacy claims; this rule enforces that requirement for the plan.

Result of noncomplianceClaims submitted with J3490, J3590, or C9399 for listed drugs will be denied for medical/UB reimbursement; such drugs must be billed under the outpatient pharmacy benefit.

Billing and Reimbursement Actions

Denial Risk

Denial of medical/UB reimbursement; pharmacy benefit required

Denial of medical/UB reimbursement: Certain specialty injectable medications must be billed and will only be reimbursed under the outpatient pharmacy benefit. Claims submitted on CMS-1500 or UB-04 (medical/professional or facility) for these drugs will be denied. Providers must submit charges for these medications through the member's pharmacy benefit.

Affected billing forms: CMS-1500 and UB-04 (and electronic equivalents)
Action: Do NOT bill impacted specialty injectable medications on medical/professional or facility claims
Reimbursement: Payable only via outpatient pharmacy benefit
Denial result: Medical/UB claims for listed specialty drugs will be denied

Code Definitions

J3490 / J3590 / C9399 — HCPCS miscellaneous codes (inv-05)

DefinitionJ3490, J3590, and C9399 are HCPCS miscellaneous/unclassified drug codes that may be used when a drug-specific J- or Q-code is not available.

Policy positionUse of J3490, J3590, or C9399 to bill drugs listed in this policy does not meet reimbursement criteria on medical professional or UB claims — such submissions are not reimbursable.

When encounteredIf a drug in the Coverage Rationale lacks a specific J- or Q-code and is billed with J3490/J3590/C9399, deny medical/UB payment and direct billing to the outpatient pharmacy benefit per AHCCCS guidance.

Related codes (examples)Some listed drugs have assigned codes (e.g., Q2055, J0180, J0221, J0598, J1411, J3404); when a specific code exists, it should be used instead of miscellaneous codes.