CurrentOscar HealthPolicy N/A

National Drug Code (NDC)

Defines Oscar Health requirements for reporting National Drug Codes (NDCs) and units of measure for drug reimbursement on professional and outpatient claims; applies to providers billing Oscar for drug products.

Policy Summary

PayerOscar Health

PolicyNational Drug Code (NDC)

Policy CodePolicy N/A

Change TypeTechnical/operational (no material coverage changes)

Effective DateJul 1, 2025

Next Review DateMay 5, 2025

Key ActionSubmit a valid FDA-listed NDC with applicable HCPCS/CPT/Revenue codes and report units using UN, ML, or GM; bill convenience kit components separately.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredNDC required for reimbursement on CMS-1500 and UB-04 professional/outpatient drug claims

Marketable carton NDCOscar does not accept inner-layer/multi-level package NDCs — use marketable carton/package NDC

Non-reimbursablePoint-of-use convenience kits are non-reimbursable; components must be billed separately

JW/JZ allowedModifiers JW (waste) and JZ (zero waste) accepted for single-dose vials

Alignment

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.

Reimbursement Conditions

NDC reimbursement criteria

Reimbursement is conditioned on submission of valid, matching NDC and adherence to unit/modifier rules.

Drugs are reimbursed only when subject to coverage and medical necessity and when all policy restrictions are met.

A valid FDA-listed NDC must be submitted for professional (CMS-1500) and outpatient (UB-04) drug claims; Oscar aligns with the FDA directory for valid NDCs and does not accept inner-layer or multi-level package (non-marketable) NDCs — use the marketable carton/package NDC.

NDC information that is invalid, missing, or not matching the HCPCS or CPT code will make the claim ineligible for reimbursement.

Report NDC units consistent with the NCPDP Billing Unit Standard: use UN for discrete units, ML for milliliters, or GM for grams as appropriate, and ensure the NDC units correspond to the numeric quantity administered.

Point-of-use convenience kits are not reimbursable as kits; bill each component separately; practice expense payments may already include supplies.

When reporting pharmaceutical waste from single-dose vials, report administered units on one claim line and report the discarded amount on a separate claim line with modifier JW appended; use modifier JZ when zero waste.

Codes requiring NDC

Drug-related CPT codes (including miscellaneous and unlisted drug codes, immunizations, Synagis, and Immune Globulin).
Drug-related Q codes (including miscellaneous, unlisted, and contrast drugs).
Drug-related J/A/$/other HCPCS codes including radiopharmaceuticals and miscellaneous/unlisted drug codes.

Unit of measure guidance: Use 'UN' for discrete items (tablets, capsules, patches, kits, etc.), 'ML' for liquid volumes (injectables, liquids >=1 mL, reconstituted volumes), and 'GM' for products measured by weight (creams/ointments >=1 gram); unit-of-use packages <1 mL or <1 GM should be billed as one each.

Codes, Units, and Modifiers

NDCNDC

NDC	National Drug Code identifier required to be submitted with drug billing

Modifiers for waste reportingModifierCovered

JW	Modifier for discarded amount of single-dose vial
JZ	Modifier indicating zero waste

NDC unit of measure

NCPDP billing units requiredUse UN for discrete units, ML for milliliters, GM for grams per the NCPDP Billing Unit Standard

UN (unit)Used for products dispensed in discrete units (tablets, capsules, patches, kits, etc.); unit-of-use packages <1 mL or g billed as one each

ML (milliliter)Used when product is measured by liquid volume (liquid injectables, non-injectable liquids ≥1 mL, reconstituted final volumes, inhalers labeled mL)

GM (gram)Used when product is measured by weight (creams/ointments ≥1 gram, inhalers labeled g)

Billing and Submission Requirements

Billing Rule

NDC submission and unit reporting

Submit a valid, FDA-listed NDC for the administered drug in addition to the applicable HCPCS, CPT, or Revenue code(s). NDC information that is missing, invalid, not FDA-listed, or that does not match the drug represented by the HCPCS/CPT code may be denied and will not be eligible for reimbursement. Oscar follows the FDA directory: do not submit NDCs that represent inner/package components that are not marketed individually — use the marketable carton/package NDC when reporting multi-level packaged products.

Always submit the numeric NDC and the corresponding NDC unit of measure and quantity in addition to the HCPCS/CPT/Revenue code and its units.
Oscar-aligned NDC validation: only FDA-listed/marketable-package NDCs are accepted; inner-layer (non-marketed) NDCs are not valid.
Affected codes: all drug-related CPT/HCPCS/Q/A/$ codes (including miscellaneous and unlisted drug codes), immunizations, Synagis, immune globulin, contrast, radiopharmaceuticals, and other drug-related codes noted by payer.

Billing Rule

Key Terms

NDC (National Drug Code)

DefinitionNational Drug Code (NDC): a numeric industry-standard identifier maintained by the U.S. FDA that identifies manufacturer, drug name, dosage/strength, package size and quantity

FDA directoryThe FDA maintains an NDC directory of finished drug products, unfinished drugs and compounded products

PurposeProvides transparency about the medication administered and links product to manufacturer and package information

NDC unit-of-measure definitions

UNUnit for discrete items (tablets, capsules, suppositories, patches, non-filled syringes, tapes, blister packs, kits, etc.)

MLMilliliter for products measured by liquid volume (liquid injectables, non-injectables ≥1 mL, reconstituted final volumes, inhalers labeled mL)