ModifiedFallon Community Health Plan IncPolicy N/A

Drugs and Biologicals Payment Policy — Physician/Clinician‑Administered Drugs

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Governs reimbursement, billing, prior authorization, and reporting requirements for medically necessary non–self-administered drugs and biologicals under Fallon Community Health Plan products; affects contracted providers, hospitals, clinics, PACE programs, and others administering medical-benefit drugs.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyDrugs and Biologicals Payment Policy — Physician/Clinician‑Administered Drugs

Policy CodePolicy N/A

Change TypeMaterial additions (Opioid reversal mappings, Spravato® HCPCS guidance, LAI billing rules)

Effective DateJan 1, 2025

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionOrdering physician must obtain prior authorization for drugs and biologicals that require Plan prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added a new section on Opioid Reversal Agents with product and code mappings (NDCs, GPI-14 descriptions, and HCPCS where present).

Added Spravato® (Esketamine) Nasal Spray billing and coding update specifying required HCPCS codes (G2082/G2083) and effective dates for various member groups.

Added guidance that HCPCS code S0013 (Esketamine, nasal spray, 1 mg) will deny (vendor liable) for certain plan types effective specified dates.

Added Long-Acting Injectable (LAI) Antipsychotics guidance for MassHealth ACO members including billing instructions for in-state acute inpatient hospitals with DMH licensed beds.

11,12,19,22PA routing POS since Oct 1, 2024

APAD/APEC → MassHealth DUR 4/1/2025MassHealth carve-out PA routing

RequiredNDC reporting

RequiredJW/JZ modifier reporting

DeniedS0013 status

CMS-1500 requiredLAI inpatient billing

Coverage and Reimbursement Criteria

Coverage and billing criteria

Reimbursement stance and special-payment methodologies:

Plan reimburses contracted providers for medically necessary covered drugs and biologicals per the provider contract; some drugs require prior authorization.

Acute outpatient hospitals reimbursed under MassHealth receive an episode-specific all‑inclusive payment (APEC) that is payment in full for most physician‑administered drugs delivered on a single calendar day; certain Fee Schedule Drugs are reimbursed separately per Medicare Part B Drug ASP pricing.

MassHealth APAD/APEC carve-out drugs (e.g., CAR T/gene therapies) are reviewed and reimbursed by the MassHealth DUR Program effective April 1, 2025; Fallon will continue to review and pay related professional and facility services.

Claims must include Level II HCPCS (and revenue code on facility claims) and, where required, valid NDC information (qualifier, 11‑digit NDC, unit qualifier, quantity); vaccines are excluded from NDC rebate reporting requirement.

Unlisted or miscellaneous HCPCS (e.g., J3490/J3590) require NDC information for Fallon Medicare Plus and Community Care members and claims without required NDC may be denied but may be resubmitted per timely filing rules.

Providers must report appropriate 340B modifiers on claim lines for 340B‑acquired drugs (MassHealth requires UD; TB required for select entities beginning Jan 1, 2025; JG used through 12/31/2024).

For separately payable Part B drugs from single‑dose containers, providers must report JW when drug amount is discarded and JZ when no discarded amount; claims without JW or JZ may be denied effective Oct 1, 2023.

Post‑Service Claims Edit (PSCE) drugs require an appropriate ICD‑10 diagnosis, appropriate frequency and unit quantity; providers should follow the Plan’s listed billing and coding guidelines.

Plan may pay for discarded amounts of single‑use vials when properly billed (separate claim lines for administered and discarded units) and documentation is retained; the Plan reserves audit rights.

Paper/electronic claim submission instructions: CMS‑1500 field 24D for HCPCS and NDC; UB‑04 field 44 for HCPCS and field 43 for NDC; format NDC per guidance.

Medical Drug Wastage Program: dose rounding to the nearest lowest vial size is required when within 10% of prescribed dose unless justified in PA request.

Drug waste reimbursement criteria

Plan reimburses drugs and biologicals administered to a Plan member only up to the next incremental Level II HCPCS code unit.

No reimbursement for portion of a multi‑use vial not administered unless documented as contaminated/wasted/unused in the patient record with date, time, and staff name; providers should use appropriately sized vials to minimize waste.

Reimbursement for discarded portions of single‑use vials is allowed only when billing/coding guidelines are followed and documentation is retained and made available for audit.

For multi‑use vials, bill only for the portion administered; wasted pharmaceutical from multi‑use vials will not be reimbursed.

Under MassHealth payment methodologies, Plan does not reimburse drug waste from single or multidose vials; JW and JZ modifiers are not allowed for MassHealth‑reimbursed physician administered drugs and providers should report quantity administered on one claim line (multiple lines for same HCPCS/date will be denied).

Claims for physician‑administered drugs must include HCPCS code, quantity administered, NDC qualifier (N4), 11‑digit NDC, NDC unit of measure and NDC quantity; include UD modifier for 340B‑acquired drugs when required.

Bevacizumab ophthalmologic billing

Use J9035 (injection, bevacizumab, 10 mg) billed one unit per eye for ophthalmologic use.

Opioid antagonists: covered under medical benefit when dispensed by a facility and under pharmacy benefit when dispensed by a pharmacist; no prior authorization required when dispensed under a state standing order; billing must use revenue code 0636 with appropriate HCPCS/NDC and ICD‑10 F11.1‑F11.99; reimbursement will not exceed Plan's average in‑network pharmacy rate and facilities may not balance bill.

For no‑cost drugs in OPPS hospital outpatient, report HCPCS with appropriate units and use a token charge <$1.01 to avoid edits and permit payment of administration charges.

Home infusion drugs for Medicare members covered under Part D must follow CMS Part D billing requirements (refer to Plan formulary and Part D guidance).

Opioid Reversal Agents (Naloxone/Nalmefene)

Opioid reversal agents and related products listed with NDCs, GPI‑14 descriptions, and HCPCS mappings are included for applicability and billing.

The policy lists opioid reversal products (naloxone/nalmefene) with specific NDCs, product labels and GPI‑14 descriptions and maps many to HCPCS codes such as J2312, J2313 and J3490 as applicable; providers should bill using the mapped HCPCS where available.

Examples from the list include prefilled naloxone syringes and nasal sprays with NDCs mapped to J2312 (prefilled syringes 2 mg/2 mL and 0.4 mg/mL) and J2313 (ZIMHI prefilled syringe 5 mg/0.5 mL), and multiple naloxone nasal spray NDCs mapped to J3490 when no specific HCPCS exists.

Where an opioid reversal product maps to an unclassified HCPCS (e.g., J3490), include the NDC on the claim per NDC reporting requirements.

Spravato® (Esketamine) Nasal Spray

Spravato® (Esketamine) billing and coding requirements and denial rules.

Effective 09/01/2025 (Medicare HMO, NaviCare, Summit ElderCare PACE, Fallon Health Weinberg PACE) and 12/01/2025 (Community Care), providers must use HCPCS G2082 or G2083 to report provision of Spravato® and associated professional services.

G2082/G2083 reimbursement includes evaluation and management of an established patient, provision of esketamine (up to or greater than 56 mg as specified) and 2 hours post‑administration observation; only one unit of G2082 or G2083 may be reported per date of service.

Spravato® (G2082, G2083) requires prior authorization.

HCPCS S0013 (Esketamine, nasal spray, 1 mg) will deny (vendor liable) for the specified plan lines effective the dates above and must not be used for those members.

If the supervising clinician does not also provide the Spravato® product/service, G2082/G2083 should not be reported; instead use appropriate E/M and prolonged service codes to describe the visit and observation.

LAI Antipsychotics in Inpatient Psychiatry Units

MassHealth ACO Long‑Acting Injectable Antipsychotics billing instructions for in‑state acute inpatient hospitals with DMH licensed beds.

LAI Antipsychotics administered in inpatient psychiatry units are identified on the MassHealth Drug List and, when so administered, are reimbursable outside of applicable per‑diem rates for in‑state acute inpatient hospitals with DMH licensed beds.

In‑state acute inpatient hospitals with DMH licensed beds must exclude charges corresponding to LAI Antipsychotics from any facility/institutional claim for the member's acute inpatient stay.

Hospitals must instead submit separate professional claims (CMS‑1500 or electronic equivalent) for the LAI Antipsychotic using the appropriate HCPCS and NDC information and submit to Fallon Health; drug‑specific prior authorization criteria, if applicable, must be met as a condition of payment.

Code Reporting and Billing Identifiers

Key billing identifiers and modifiersmixed

HCPCS	Drugs and biologicals identified by HCPCS on professional claims; Level II HCPCS codes used on CMS-1500 (24D) and UB-04 (field 44).
NDC	11-digit NDC required with qualifier and unit of measure on claims when reporting clinician-administered drugs; vaccines excluded from rebate requirement.
Revenue	Revenue code plus HCPCS combination used on facility claims; specific guidance for revenue 025X and splitting lines when single drug amount ≥ $10,000.
Modifiers JW/JZ	Report JW for discarded drug amounts and JZ to attest no discarded amounts for single-dose Part B drugs/biologics.
Modifiers TB/JG/UD	340B reporting modifiers: JG (terminated 12/31/2024), TB required for 2025 for certain entities; MassHealth requires UD for 340B-acquired drugs.

Ophthalmologic bevacizumab (J9035)HCPCSCovered

J9035

Injection, bevacizumab, 10 mg — ophthalmologic use; bill one unit per eye

Opioid reversal agents (selected mappings)HCPCSCovered

J2312	Naloxone HCl injection codes listed for opioid reversal agents
J3490	Unclassified drugs — used for certain naloxone and nalmefene nasal sprays per mapping

No-cost vaccine reportingModifier

SL	Modifier to indicate state-supplied vaccine (attach to vaccine/toxoid CPT with $0.00 charge); hospitals may submit token charge < $1.01 and mirror in Non-Covered Charge when required.

Opioid reversal product code mappingsHCPCSCovered

J2312	Naloxone HCl solution prefilled syringes and injections (multiple NDCs mapped to J2312)
J2313	Naloxone HCl solution prefilled syringe 5 mg/0.5 mL (ZIMHI) — mapped to J2313
J3490	Unclassified drugs — used for certain naloxone/nalmefene nasal spray products (multiple NDCs mapped to J3490)

Spravato® / Esketamine HCPCS guidanceHCPCSCovered

G2082	Office/outpatient visit for E/M of established patient with supervised esketamine up to 56 mg including 2 hours post-administration observation; only 1 unit may be reported per date of service.
G2083	Office/outpatient visit for E/M of established patient with supervised esketamine greater than 56 mg including 2 hours post-administration observation; only 1 unit may be reported per date of service.
S0013	Esketamine, nasal spray, 1 mg — Not valid for Medicare; claims for S0013 will deny (vendor liable) for specified plans effective stated dates.

025X claim line threshold — NDC requirement when single 025X line >= $10,000

ThresholdWhen a single drug amount on revenue code 025X is equal to or greater than $10,000, NDC information is required on the claim; if multiple drugs are combined on a 025X line and the total is ≥ $10,000, split lines so no single 025X line is ≥ $10,000.

ActionSplit combined drugs on 025X revenue lines so each line is below the $10,000 threshold to avoid mandatory NDC reporting or potential denials.

Reporting noteAll claims with drug HCPCS codes must include a corresponding NDC; the 025X threshold is an additional NDC trigger for facility claims.

Reimbursement cap per administered amount — reimburses up to next incremental Level II HCPCS code unit

Reimbursement capThe Plan reimburses drugs and biologicals administered to a Plan member only up to the next incremental Level II HCPCS code unit.

Multi-use vial ruleNo reimbursement for portion of a multi-use vial not administered to members; only the portion administered is billable unless documented for single-use vials.

Documentation requirementReimbursement for discarded portions of single-use vials is allowed only when proper billing/coding guidelines are followed and documentation is retained and available for audit.

Provider Responsibilities and Prior Authorization

Prior Authorization

Obtain prior authorization when required

Ordering physician must obtain prior authorization for drugs and biologicals that require Plan prior authorization; the list of drugs and biologicals that require prior authorization is available online at Fallon Health Pharmacy Prior Authorization.

Prior Authorization

Route prior authorization requests to Prime Therapeutics for specified POS

Since October 1, 2024, Prime Therapeutics reviews prior authorization requests for physician/clinician‑administered drugs provided in Places of Service 11, 12, 19 and 22; providers must submit PA requests to Prime via their secure portal (https://gateway.pa.com/) or fax (1‑888‑656‑6671) and may call Prime at 1‑800‑424‑1740 for assistance.

For drugs administered in POS other than 11, 12, 19 and 22, submit PA requests to Fallon Health (electronic, fax, mail or telephone).
If Prime portal is inaccessible, fax to 1‑888‑656‑6671.

Prior Authorization

Submit MassHealth APAD/APEC carve-out drug PAs to MassHealth DUR

Effective April 1, 2025, prior authorization requests for MassHealth APAD and APEC carve-out drugs must be submitted to the MassHealth Drug Utilization Review (DUR) Program for review and approval before administration; Fallon will continue to review and pay related professional and facility services.

The MassHealth APAD/APEC carve-out list (e.g., CAR T/gene therapies) is available at the MassHealth Drug List website.
Only the carve-out drugs themselves will be reviewed and reimbursed by MassHealth; submitters must use the DUR Program for PA of these drugs for dates of service on or after 4/1/2025.

Documentation Required

Obtain Interdisciplinary Team approval for PACE members

PACE plan members require approval of care and services by the member's Interdisciplinary Team except for emergency care and out‑of‑area urgently needed care; providers must ensure Interdisciplinary Team approval prior to providing non‑urgent services.

Billing Rule

Report JW/JZ modifiers for discarded or zero discarded amounts

Providers must report the JW modifier when a drug amount from a single‑dose container or single‑use package is discarded and the JZ modifier to attest that no drug amount was discarded; claims for separately payable Part B drugs from single‑dose containers or single‑use packages that do not report JW or JZ as appropriate may be subject to audits and, effective October 1, 2023, will be denied.

Document discarded amounts in the member's medical record (date, time, staff name) as required by CMS guidance.
JW/JZ modifiers are not appropriate for multi‑dose containers, packaged OPPS/ASC drugs, or drugs administered in RHC/FQHC settings.

Prior Authorization

Opioid antagonists dispensed under state law do not require PA

Opioid antagonists dispensed pursuant to Massachusetts law and the statewide standing order do not require prior authorization or an individual prescription when dispensed under the standing order; coverage is provided under the medical benefit when dispensed by the facility and under the pharmacy benefit when dispensed by a pharmacist.

When dispensed by facilities, bill using revenue code 0636 with the appropriate HCPCS, NDC and ICD‑10 F11.1–F11.99.
Pharmacist dispensing under M.G.L. c.94C, §19B is allowed without individual prescription; refer to the Mass. standing order for naloxone.

Prior Authorization

Prior authorization required for Spravato® (G2082/G2083)

Spravato® (esketamine) reported with HCPCS G2082 or G2083 requires prior authorization; providers must use G2082/G2083 for applicable member groups per the effective dates listed in the policy.

Effective 09/01/2025: use G2082 or G2083 for Medicare HMO, NaviCare, Summit ElderCare PACE, and Weinberg PACE members.
Effective 12/01/2025: use G2082 or G2083 for Community Care members.
Only one unit of G2082 or G2083 may be reported per date of service.

Prior Authorization

Meet PA criteria and bill LAI antipsychotics on professional claim

Drug‑specific prior authorization criteria, if applicable, must be met as a condition of payment for Long‑Acting Injectable (LAI) antipsychotics administered in inpatient psychiatry units; hospitals must exclude LAI drug charges from facility/institutional claims and submit separate professional claims (CMS‑1500) with the appropriate HCPCS and NDC.

Exclude LAI antipsychotic charges from the inpatient facility claim and bill the drug on a professional claim (CMS‑1500) to Fallon Health.
LAI Antipsychotics are identified on the MassHealth Long‑Acting Injectable Antipsychotic list; follow that list and MassHealth billing guidance.

Key Terms and Modifiers

Physician/Clinician-administered drugs — definition and scope of medical-benefit drugs

DefinitionMedical-benefit drugs (Physician/Clinician-administered drugs) are non–self-administered drugs and biologicals typically given by injection or infusion in a physician's office, clinic, hospital, or sometimes in the patient's home.

Claim identifiersPhysician/clinician-administered drugs must be identified on a claim by HCPCS code, NDC, NDC qualifier and NDC quantity.

NDC rebate contextValid NDCs are required on claims to facilitate manufacturer rebate collection for the Massachusetts Medicaid Program; vaccines are excluded from the NDC reporting requirement per the Social Security Act.

JW/JZ modifiers — definitions for JW and JZ modifier usage

JW modifierReport JW to identify the drug amount discarded (not administered to any patient) when discarding remainder of a single‑dose container or single‑use package; file a second claim line with the same billing code, JW modifier, and units discarded.

JZ modifierReport JZ to attest there are zero discarded amounts for single‑dose containers or single‑use packages when the JW modifier would otherwise be required if there were discarded amounts.

ApplicabilityJW/JZ modifiers apply to separately payable Part B drugs from single‑dose containers or single‑use packages; they do not apply to multi‑dose containers, packaged OPPS/ASC drugs, RHCs or FQHCs.

NDC Information — required NDC qualifier, 11-digit NDC, unit qualifier and quantity reporting rules

Required elementsWhen reporting an NDC on a claim include: NDC Qualifier (F4), the 11‑digit NDC, NDC Unit of Measure Qualifier (F2, GR, ME, UN, ML) and NDC quantity.

Unit qualifiersExamples of unit qualifiers: F2 = International Unit, GR = Gram, ME = Milligram, UN = Unit (tablets/capsules), ML = Milliliter.

When requiredNDC information is required on all claims with drug HCPCS codes and specifically required for physician‑administered drugs billed with revenue code 025X when a single drug amount is ≥ $10,000.

Discarded amount definition — how discarded amount is determined

DefinitionDiscarded amount is any amount not part of the prescribed dose and not intended to have therapeutic effect; generally the labeled amount on the single‑dose container (or containers if more than one is required) minus the dose administered.

DocumentationProviders must document discarded drug amounts in the member's medical record per CMS requirements (e.g., Transmittal R3538CP; MLN Matters MM9603).

ClaimingWhen discarded amounts exist, file a second claim line with the JW modifier to identify the discarded units; the Plan will not pay for JW‑billed drug unless a corresponding administered line is present.

JW = Drug amount discarded/not administered to any patient — concise definition

JW — conciseJW = Drug amount discarded/not administered to any patient; used to report the discarded units from a single‑dose container or single‑use package.

Claim handlingWhen reporting JW, submit a second claim line with the same billing code, the JW modifier, and the number of units discarded; the Plan will pay for discarded amount only if properly billed with the administered line on the claim.

DocumentationProviders must document discarded amounts in the medical record (date, time, staff name) in accordance with CMS guidance.

JZ = Zero drug amount discarded/not administered to any patient — concise definition

JZ — conciseJZ = Zero drug amount discarded/not administered to any patient; used to attest no discarded amounts for single‑dose containers or single‑use packages.

TimingProviders were required to report JZ beginning July 1, 2023; failure to report JW or JZ may result in audits and denials (effective Oct 1, 2023).

ScopeJZ applies where JW would be required if there were discarded amounts; it is not appropriate for multi‑dose containers or non‑separately payable drugs.

Long-Acting Injectable (LAI) Antipsychotics — definition distinguishing medication product from administration service

DefinitionLAI Antipsychotics are antipsychotic medications administered via intramuscular injection that provide medication coverage for weeks to months; the term refers to the medication product, not the administration service.

ListingLAI medications are identified on the MassHealth Long‑Acting Injectable Antipsychotic list published on the MassHealth Drug List website.

Billing implicationFor in‑state acute inpatient hospitals with DMH licensed beds, LAI charges must be excluded from facility/institutional claims and billed on a professional claim (CMS‑1500) using appropriate HCPCS and NDC information.

G2082/G2083 service scope — outpatient visit including supervision and 2-hour observation; only one unit per date of service

Service scopeHCPCS G2082/G2083 describe an outpatient visit that includes supervision of esketamine nasal self‑administration and 2 hours post‑administration observation; reimbursement includes the evaluation/management, Spravato® provision and the 2‑hour observation.

Unit restrictionOnly one unit of G2082 or G2083 may be reported per date of service.

Reporting constraintIf the supervising clinician does not also provide the Spravato® product, G2082/G2083 cannot be reported; use existing E/M and prolonged service codes instead.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyDrugs and Biologicals Payment Policy — Physician/Clinician‑Administered Drugs

Policy CodePolicy N/A

Change TypeMaterial additions (Opioid reversal mappings, Spravato® HCPCS guidance, LAI billing rules)

Effective DateJan 1, 2025

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionOrdering physician must obtain prior authorization for drugs and biologicals that require Plan prior authorization.

SourceLink

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Drugs and Biologicals Payment Policy — Physician/Clinician‑Administered Drugs

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Coverage and Reimbursement Criteria

Coverage and billing criteria

Reimbursement stance and special-payment methodologies:

Plan reimburses contracted providers for medically necessary covered drugs and biologicals per the provider contract; some drugs require prior authorization.

Providers must report appropriate 340B modifiers on claim lines for 340B‑acquired drugs (MassHealth requires UD; TB required for select entities beginning Jan 1, 2025; JG used through 12/31/2024).

Post‑Service Claims Edit (PSCE) drugs require an appropriate ICD‑10 diagnosis, appropriate frequency and unit quantity; providers should follow the Plan’s listed billing and coding guidelines.

Paper/electronic claim submission instructions: CMS‑1500 field 24D for HCPCS and NDC; UB‑04 field 44 for HCPCS and field 43 for NDC; format NDC per guidance.

Medical Drug Wastage Program: dose rounding to the nearest lowest vial size is required when within 10% of prescribed dose unless justified in PA request.

Drug waste reimbursement criteria

Plan reimburses drugs and biologicals administered to a Plan member only up to the next incremental Level II HCPCS code unit.

Reimbursement for discarded portions of single‑use vials is allowed only when billing/coding guidelines are followed and documentation is retained and made available for audit.

For multi‑use vials, bill only for the portion administered; wasted pharmaceutical from multi‑use vials will not be reimbursed.

Bevacizumab ophthalmologic billing

Use J9035 (injection, bevacizumab, 10 mg) billed one unit per eye for ophthalmologic use.

For no‑cost drugs in OPPS hospital outpatient, report HCPCS with appropriate units and use a token charge <$1.01 to avoid edits and permit payment of administration charges.

Home infusion drugs for Medicare members covered under Part D must follow CMS Part D billing requirements (refer to Plan formulary and Part D guidance).

Opioid Reversal Agents (Naloxone/Nalmefene)

Opioid reversal agents and related products listed with NDCs, GPI‑14 descriptions, and HCPCS mappings are included for applicability and billing.

Where an opioid reversal product maps to an unclassified HCPCS (e.g., J3490), include the NDC on the claim per NDC reporting requirements.

Spravato® (Esketamine) Nasal Spray

Spravato® (Esketamine) billing and coding requirements and denial rules.

Spravato® (G2082, G2083) requires prior authorization.

HCPCS S0013 (Esketamine, nasal spray, 1 mg) will deny (vendor liable) for the specified plan lines effective the dates above and must not be used for those members.

LAI Antipsychotics in Inpatient Psychiatry Units

MassHealth ACO Long‑Acting Injectable Antipsychotics billing instructions for in‑state acute inpatient hospitals with DMH licensed beds.

In‑state acute inpatient hospitals with DMH licensed beds must exclude charges corresponding to LAI Antipsychotics from any facility/institutional claim for the member's acute inpatient stay.

Code Reporting and Billing Identifiers

Key billing identifiers and modifiersmixed

HCPCS	Drugs and biologicals identified by HCPCS on professional claims; Level II HCPCS codes used on CMS-1500 (24D) and UB-04 (field 44).
NDC	11-digit NDC required with qualifier and unit of measure on claims when reporting clinician-administered drugs; vaccines excluded from rebate requirement.
Revenue	Revenue code plus HCPCS combination used on facility claims; specific guidance for revenue 025X and splitting lines when single drug amount ≥ $10,000.
Modifiers JW/JZ	Report JW for discarded drug amounts and JZ to attest no discarded amounts for single-dose Part B drugs/biologics.
Modifiers TB/JG/UD	340B reporting modifiers: JG (terminated 12/31/2024), TB required for 2025 for certain entities; MassHealth requires UD for 340B-acquired drugs.

Ophthalmologic bevacizumab (J9035)HCPCSCovered

J9035

Injection, bevacizumab, 10 mg — ophthalmologic use; bill one unit per eye

Opioid reversal agents (selected mappings)HCPCSCovered

J2312	Naloxone HCl injection codes listed for opioid reversal agents
J3490	Unclassified drugs — used for certain naloxone and nalmefene nasal sprays per mapping

No-cost vaccine reportingModifier

SL	Modifier to indicate state-supplied vaccine (attach to vaccine/toxoid CPT with $0.00 charge); hospitals may submit token charge < $1.01 and mirror in Non-Covered Charge when required.

Opioid reversal product code mappingsHCPCSCovered

J2312	Naloxone HCl solution prefilled syringes and injections (multiple NDCs mapped to J2312)
J2313	Naloxone HCl solution prefilled syringe 5 mg/0.5 mL (ZIMHI) — mapped to J2313
J3490	Unclassified drugs — used for certain naloxone/nalmefene nasal spray products (multiple NDCs mapped to J3490)

Spravato® / Esketamine HCPCS guidanceHCPCSCovered

G2082	Office/outpatient visit for E/M of established patient with supervised esketamine up to 56 mg including 2 hours post-administration observation; only 1 unit may be reported per date of service.
G2083	Office/outpatient visit for E/M of established patient with supervised esketamine greater than 56 mg including 2 hours post-administration observation; only 1 unit may be reported per date of service.
S0013	Esketamine, nasal spray, 1 mg — Not valid for Medicare; claims for S0013 will deny (vendor liable) for specified plans effective stated dates.

025X claim line threshold — NDC requirement when single 025X line >= $10,000

ActionSplit combined drugs on 025X revenue lines so each line is below the $10,000 threshold to avoid mandatory NDC reporting or potential denials.

Reporting noteAll claims with drug HCPCS codes must include a corresponding NDC; the 025X threshold is an additional NDC trigger for facility claims.

Reimbursement cap per administered amount — reimburses up to next incremental Level II HCPCS code unit

Reimbursement capThe Plan reimburses drugs and biologicals administered to a Plan member only up to the next incremental Level II HCPCS code unit.

Multi-use vial ruleNo reimbursement for portion of a multi-use vial not administered to members; only the portion administered is billable unless documented for single-use vials.

Provider Responsibilities and Prior Authorization

Prior Authorization

Obtain prior authorization when required

Prior Authorization

Route prior authorization requests to Prime Therapeutics for specified POS

For drugs administered in POS other than 11, 12, 19 and 22, submit PA requests to Fallon Health (electronic, fax, mail or telephone).
If Prime portal is inaccessible, fax to 1‑888‑656‑6671.

Prior Authorization

Submit MassHealth APAD/APEC carve-out drug PAs to MassHealth DUR

The MassHealth APAD/APEC carve-out list (e.g., CAR T/gene therapies) is available at the MassHealth Drug List website.
Only the carve-out drugs themselves will be reviewed and reimbursed by MassHealth; submitters must use the DUR Program for PA of these drugs for dates of service on or after 4/1/2025.

Documentation Required

Obtain Interdisciplinary Team approval for PACE members

Billing Rule

Report JW/JZ modifiers for discarded or zero discarded amounts

Document discarded amounts in the member's medical record (date, time, staff name) as required by CMS guidance.
JW/JZ modifiers are not appropriate for multi‑dose containers, packaged OPPS/ASC drugs, or drugs administered in RHC/FQHC settings.

Prior Authorization

Opioid antagonists dispensed under state law do not require PA

When dispensed by facilities, bill using revenue code 0636 with the appropriate HCPCS, NDC and ICD‑10 F11.1–F11.99.
Pharmacist dispensing under M.G.L. c.94C, §19B is allowed without individual prescription; refer to the Mass. standing order for naloxone.

Prior Authorization

Prior authorization required for Spravato® (G2082/G2083)

Spravato® (esketamine) reported with HCPCS G2082 or G2083 requires prior authorization; providers must use G2082/G2083 for applicable member groups per the effective dates listed in the policy.

Effective 09/01/2025: use G2082 or G2083 for Medicare HMO, NaviCare, Summit ElderCare PACE, and Weinberg PACE members.
Effective 12/01/2025: use G2082 or G2083 for Community Care members.
Only one unit of G2082 or G2083 may be reported per date of service.

Prior Authorization

Meet PA criteria and bill LAI antipsychotics on professional claim

Exclude LAI antipsychotic charges from the inpatient facility claim and bill the drug on a professional claim (CMS‑1500) to Fallon Health.
LAI Antipsychotics are identified on the MassHealth Long‑Acting Injectable Antipsychotic list; follow that list and MassHealth billing guidance.