CurrentHighmark PennsylvaniaPolicy N/A

Highmark List of Procedure Codes Requiring NDC

A Highmark Pennsylvania reimbursement/policy list identifying HCPCS/CPT procedure codes that require submission of an NDC (National Drug Code) effective 07/01/2024; applies to providers billing Highmark Pennsylvania for the listed injectable/oral drug administrations.

Policy Summary

PayerHighmark Pennsylvania

PolicyHighmark List of Procedure Codes Requiring NDC

Policy CodePolicy N/A

Change TypeInformational — new billing requirement

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionProviders must submit the National Drug Code (NDC) on claims for the listed HCPCS/HCPCS J/Q procedure codes when billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

07/01/2024Requirement effective

~320Approx. codes listed

yesIncludes unclassified codes

multipleTherapeutic classes

Procedure Codes Requiring NDC — Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: Codes requiring NDC (partial list)

The following HCPCS / J-codes require submission of the corresponding National Drug Code (NDC) on the claim when billed to Highmark Pennsylvania (partial list).

When billing any of the HCPCS/J codes listed below, the claim must include the corresponding NDC to identify the drug product.

Examples (partial)

90378 — RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINANT, FOR INTRAMUSCULAR USE, 50 MG, EACH
C9399 — UNCLASSIFIED DRUGS OR BIOLOGICALS
J0121 — INJECTION, OMADACYCLINE, 1 MG
J0456 — INJECTION, AZITHROMYCIN, 500 MG
J0457 — INJECTION, AZTREONAM, 100 MG

inv-02: NDC submission requirement

When submitting claims for the HCPCS/J procedure codes listed below, the claim must include the corresponding NDC.

NDC submission is required on claims for the listed HCPCS/J procedure codes; omission of the NDC may result in claim rejection or denial.

Selected codes (partial)

J1571 — INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML
J1595 — INJECTION, GLATIRAMER ACETATE, 20 MG
J1745 — INJECTION, INFLIXIMAB, 10 MG
J1602 — INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE

inv-03: NDC submission requirement (billing rule)

Billing rule: for the specific HCPCS/Q/J codes shown, providers must report the product NDC on the claim.

When billing any HCPCS/Q/J code listed in Highmark's procedure code list, submit the corresponding NDC on the claim to identify the drug/biologic product.

Example entries (partial)

J7294 — WILLEBRAND FACTOR COMPLEX, RECOMBINANT (ALTUVIIIO), PER FACTOR VIII A.U.
J9306 — INJECTION, PERTUZUMAB, 1 MG
J9310 — INJECTION, RITUXIMAB, 100 MG
J9395 — INJECTION, FULVESTRANT, 25 MG

inv-04: Product-specific eligibility snippets

Product-specific eligibility notes where provided in the list.

Q0220 / Q0221 — Tixagevimab and cilgavimab are listed for pre‑exposure prophylaxis; when billing these codes include the NDC. See age/weight eligibility below.

Age and weight requirement — applies to Q0220/Q0221: patient must be 12 years of age or older AND weigh at least 40 kg.

Operational note: ensure NDC is reported on the claim for these prophylaxis products in addition to confirming patient age and weight eligibility as specified.

Code Lists and Examples

Sample codes from list (partial)mixed

90378	RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINANT, FOR INTRAMUSCULAR USE, 50 MG, EACH
C9399	UNCLASSIFIED DRUGS OR BIOLOGICALS
J0121	INJECTION, OMADACYCLINE, 1 MG

Sample J-codes requiring NDCHCPCS

J1571	INJECTION, HEPATITIS B IMMUNE GLOBULIN HEPAGAM B, INTRAMUSCULAR, 0.5 ML
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG
J1745	INJECTION, INFLIXIMAB, 10 MG

Example HCPCS/J codes requiring NDCHCPCS

J7294	WILLEBRAND FACTOR COMPLEX, RECOMBINANT (ALTUVIIIO), PER FACTOR VIII A.U.
J7295	ETHINYL ESTRADIOL AND ETONOGESTREL, 0.015MG, 0.12MG PER 24 HOURS; MONTHLY VAGINAL RING, EACH
J7300	INTRAUTERINE COPPER CONTRACEPTIVE

Antineoplastic/oncology J-codes requiring NDCHCPCS

J9000	DOXORUBICIN HCL, 10 MG
J9022	INJECTION, ATEZOLIZUMAB, 10 MG
J9264	PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG

Selected J-codes requiring NDCHCPCS

J9354	MARGETUXIMAB-CMKB, 5 MG
J9355	ADO-TRASTUZUMAB EMTANSINE, 1 MG
J9356	TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG
J9395	FULVESTRANT, 25 MG
J9400	ZIV-AFLIBERCEPT, 1 MG

Selected biosimilar Q-codes requiring NDCHCPCS

Q5101	FILGRASTIM-SNDZ (biosimilar)
Q5112	TRASTUZUMAB-DTTB (biosimilar)
Q5124	RANIBIZUMAB-NUNA (biosimilar)
Q5131	ADALIMUMAB-AACF (biosimilar)

Selected S-codes and other HCPC entriesHCPCS

S5550	INSULIN, RAPID ONSET; 5 UNITS
S0013	ESKETAMINE, NASAL SPRAY, 1 MG
S0104	ZIODVUDINE, ORAL, 100 MG

Unclassified drug/biologic codes requiring NDC

Included unclassified codesJ3490, J3590, J3591 are included in the list and therefore require submission of an NDC when billed

C9399 referenceC9399 is listed as 'UNCLASSIFIED DRUGS OR BIOLOGICALS' and captured in the NDC requirement list

Scope of inclusionUnclassified codes are treated the same as other HCPCS/J-codes for NDC reporting on claims

Age and weight eligibility for Q0220/Q0221

Age requirement for Q0220/Q0221Patients must be 12 years of age or older

Weight requirement for Q0220/Q0221Patients must weigh at least 40 kg

Indication contextQ0220/Q0221 are listed for pre-exposure prophylaxis for certain adults and pediatric individuals meeting the age/weight criteria

Billing Requirements and Actions for Providers

Billing Rule

NDC Submission Requirement — Listed Procedure/HCPCS/J Codes

Providers must submit the National Drug Code (NDC) when billing any of the procedure/HCPCS/J codes listed below. Failure to report the NDC may result in claim processing delays or denial. This requirement is effective 07/01/2024.

Effective 07/01/2024: Submit NDC on all claims for the listed procedure/HCPCS/J codes.
Include product NDC, unit of measure, and number of units consistent with the billed code and dosing.

Billing Rule

NDC Requirement for Listed Procedure Codes

Providers must report the NDC for the following HCPCS/J procedure codes when submitting claims. The Highmark List of Procedure Codes Requiring NDC (effective 07/01/2024) includes, but is not limited to, the codes shown across this policy. Always reference the full Highmark code list when preparing claims.

Examples of included codes (partial list): 90378, C9399, J0121, J0122, J0129, J0130, J0135, J0153, J0172, J0177, J1571, J1572, J1595, J1602, J1627, J7294, J9354, J9355, J9356, J9358, J9360, J9370, J9371, J9380, J9381, J9390, J9395, J9400, J9600, J9999, Q0138, Q0139, Q0166, Q0167, Q0180
Providers should consult the complete Highmark list in this policy for all codes requiring NDC submission.

Billing Rule

COVID-19 Monoclonal Antibody and Prophylaxis NDC Requirement

For COVID-19 monoclonal antibodies and COVID-19 prophylaxis agents, providers must submit the NDC for the listed Q-codes and related HCPCS drug codes when billing. This includes pre-exposure prophylaxis agents and COVID-19 monoclonal antibody treatments — submit the NDC to ensure correct benefit/administration adjudication.

COVID-19 related codes requiring NDC (examples): Q0220, Q0221, Q0222, Q0224, Q0239 (and any other COVID-19 monoclonal antibody or prophylaxis HCPCS/Q-codes on the Highmark list).
These requirements apply to agents used for pre-exposure prophylaxis and monoclonal antibody treatment; include the specific product NDC and dosage for each billed unit.
Effective date: 07/01/2024 — submit NDC information on all claims for these COVID-19 related codes.

Definitions and Notes

National Drug Code (NDC) submission requirement

NDC submission requirementThe payer requires submission of the corresponding National Drug Code (NDC) on claims when billing the procedure/HCPCS codes listed in this document (effective 07/01/2024)

Effective dateRequirement effective 07/01/2024

Potential claim impactClaims without required NDC information may be subject to rejection or denial

Unclassified drug/biologic — NDC reporting

Unclassified codes includedUnclassified drug/biologic codes such as J3490 and J3590 are included in the list and require NDC reporting when used

Specific unclassified entryJ3591 is listed as 'UNCLASSIFIED DRUG OR BIOLOGICAL USED FOR ESRD ON DIALYSIS' and requires NDC

Treatment parityUnclassified codes are captured alongside specific J-/Q-/S-codes for NDC submission purposes

Procedure codes requiring NDC (definition)

DefinitionThe listed procedure/HCPCS codes are those for which an NDC must be submitted on the claim as of the stated effective date

List coverageIncludes J-codes, Q-codes, S-codes and other HCPCS identifiers enumerated in the document

Use on claimsProviders must supply the corresponding NDC for the specific drug product administered when billing any code on the list

HCPCS J-codes — correspondence to specific drug products

HCPCS/J-code meaningHCPCS J-codes listed correspond to specific drug products or formulations (for example, injections, oral chemotherapeutics, inhalation solutions)

ExamplesEntries include inhalation solutions (J7674), oral chemotherapy agents (J8510, J8520) and injectable biologics (multiple J9xxx entries)

Coding implicationEach J-code maps to a particular drug/product description that must be identified by NDC on the claim

Pre-exposure prophylaxis — term note

Term definitionPre-exposure prophylaxis (as used here) refers to administration of agents (e.g., tixagevimab and cilgavimab, Q0220/Q0221) to prevent SARS‑CoV‑2 infection in eligible individuals prior to exposure

Target population noteUsed for individuals who are moderately to severely immunocompromised or who cannot receive COVID‑19 vaccination due to severe adverse reaction

Associated codesPre-exposure prophylaxis agents in the list include Q0220, Q0221, Q0224 and related Q-codes

Biosimilar HCPCS/Q-codes — term note

Biosimilar Q-code meaningBiosimilar HCPCS/Q-codes in the list identify biosimilar versions of reference biologics (e.g., Q5112 trastuzumab-dttb, Q5124 ranibizumab-nuna)

Examples presentDocument includes multiple biosimilar entries such as Q5108 (bevacizumab-aWWB), Q5112, Q5113 and others

NDC reporting requirementBiosimilar Q-code entries are subject to the same NDC submission requirement as other listed codes