Currentmedical mutual - ohioPolicy N/A

High-Cost Outlier Specialty Drug reimbursement

Defines reimbursement method and required agreed-upon unique reimbursement rates for specified high-cost specialty drugs and lists drugs affected; applies to providers in Medical Mutual's network submitting claims for these drugs.

Policy Summary

Payermedical mutual - ohio

PolicyHigh-Cost Outlier Specialty Drug reimbursement

Policy CodePolicy N/A

Change TypeOperational routing change (cellular & gene therapies)

Effective DateDec 15, 2025

Next Review DateN/A

Key ActionProvider must contact the network management contracting team to agree upon a unique reimbursement rate prior to claims submission.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2026, cellular and gene therapy products are included in the Optum Transplant Services and not subject to the High-cost Outlier Specialty Drug process.

100% CMS or WACDefault reimbursement rate if no agreed rate

12/15/2025Policy effective date

01/01/2026Cellular & gene therapies routed

~100+Codes listed

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.

Coverage criteria for High-Cost Outlier Specialty Drug

Covered when ALL of the following requirements are met:

Provider has submitted a claim for a drug listed as a High-Cost Outlier Specialty Drug (see coding module for included HCPCS/CPT/Q-codes).

Listed codes are in the policy coding list; see coding section for full code list.

A unique reimbursement rate has been agreed upon between the provider and Medical Mutual's network management contracting team prior to claims submission.

Providers should contact the network management contracting team to establish the agreed rate before submitting the claim.

Fallback if requirement not met

No unique reimbursement rate was agreed upon prior to claim submission
Payment will be processed at 100% of the CMS assigned rate, or at 100% of the wholesale acquisition cost (WAC) if there is no Medicare assigned rate.
This is the default payment rule applied at claim adjudication when no agreed rate exists.

Cellular and gene therapy products approved by the U.S. Food & Drug Administration are excluded from this High-Cost Outlier Specialty Drug process and, effective January 1, 2026, are handled under Optum Transplant Services.

See the FDA list of approved cellular and gene therapy products for specifics; these products are not subject to the unique-rate requirement starting 01/01/2026.

The unique-rate requirement applies to the HCPCS/CPT/Q codes and product descriptions listed in the policy (including, but not limited to, A9513, J0222, J1299, J2326, J3399, Q2041–Q2058 and other codes listed in the coding module).

See the coding section for the full, authoritative list of covered codes subject to this policy.

Included Codes and Reimbursement Defaults

Included HCPCS/Codes and described productsHCPCSCovered

A9513	lutetium Lu 177 dotatate (Lutathera)
J0222	patisiran (Onpattro)
J0223	givosiran (Givlaari)
J0225	vutrisiran (Amvuttra)
J0638	canakinumab (Ilaris)
J0896	luspatercept-aamt (Reblozyl)
J1299	eculizumab (Soliris)
Q5151	eculizumab-aagh (Epysqli) - Drug added 4/23/26
Q5152	eculizumab-aeeb (Bkemv) - Drug added 4/23/26
J1303	ravulizumab-cwvz (Ultomiris)

1–10 of 64

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Default reimbursement percentage

Default reimbursement percentage100% of CMS or WAC if no Medicare assigned rate

When appliedUsed when no unique agreed reimbursement rate exists prior to claims submission

Effective date (policy requirement)Effective December 15, 2025

Provider Actions & Billing Rules

Prior Authorization

Prior agreement with network management required

Provider must contact the network management contracting team to agree upon a unique reimbursement rate prior to claims submission. The policy states the provider can contact the network management contracting team to agree upon a reimbursement rate that will be in line with 100% of CMS or the wholesale acquisition cost (WAC) if there is no Medicare assigned rate.

Agreement must be reached prior to claim submission
Contact the network management contracting team to negotiate the unique rate

Billing Rule

Default payment rule if no prior agreed rate

If no agreed-upon reimbursement rate exists at the time the claim is submitted, payment will default to one hundred percent (100%) of CMS or the wholesale acquisition cost (WAC) when there is no Medicare assigned rate. The policy specifies payment will be processed at 100% of CMS or WAC absent a prior agreement.

Default payment = 100% of CMS when a Medicare rate exists
If no Medicare assigned rate, default payment = 100% of WAC

Definitions

WAC (Wholesale Acquisition Cost)

DefinitionWholesale Acquisition Cost (WAC)

Use in policyServes as the fallback reimbursement basis when no Medicare assigned (CMS) rate exists

Related actionProviders should negotiate a unique reimbursement rate with network management to avoid defaulting to WAC

CMS rate (Medicare assigned rate)

DefinitionCMS rate — Medicare assigned rate used as the primary reimbursement basis

Policy rolePayment processed at 100% of CMS when no unique agreed reimbursement rate exists

Provider actionProviders may contact network management contracting team to establish a unique rate instead of using CMS rate

Cellular and gene therapy products (policy routing change)

Policy changeCellular and gene therapy products are included in Optum Transplant Services and are not subject to the High-Cost Outlier Specialty Drug process

Effective dateEffective January 1, 2026

Reference listComplete FDA list of approved cellular and gene therapy products is available at the FDA website specified in the policy