CurrentOscar HealthPolicy N/A

Phosphate Binders — Pharmacy Benefit Placement and Facility Reimbursement Guidance

Defines Oscar Health's reimbursement and procurement requirements for oral phosphate binders and select orally administered medications in outpatient facility settings, directing that ingredient drug costs be covered only through the member's pharmacy benefit and not billed to the medical benefit.

Policy Summary

PayerOscar Health

PolicyPhosphate Binders — Pharmacy Benefit Placement and Facility Reimbursement Guidance

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionEnsure members obtain oral phosphate binders through network pharmacies; facilities may not bill Oscar Health for the ingredient cost.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Appendix AAppendix list

J0601–J0615Denied HCPCS sample

Pharmacy onlyIngredient coverage

ReimbursedAdministration payment

Coverage and Benefit Placement

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Pharmacy benefit coverage with administrative payment only

Coverage and procurement rules for oral phosphate binders

Ingredient cost for orally administered medications listed in Appendix A is covered only when processed and dispensed through a participating pharmacy under the member's pharmacy benefit.

Oral phosphate binders are covered under the pharmacy benefit when prescribed for an FDA-approved or compendia-supported indication.

Claims for the ingredient cost of the specified oral medications submitted under the medical benefit with HCPCS or other procedure codes will be denied reimbursement.

Members must obtain these medications through Oscar Health's network pharmacies or designated specialty pharmacy partners; the prescribing provider must issue a prescription to a participating pharmacy for adjudication through the pharmacy benefit.

Facilities may not bill Oscar Health for the ingredient cost of oral phosphate binders (no buy-and-bill); facilities should not purchase these medications for Oscar Health members for billing to the medical benefit.

The Plan will reimburse medically necessary administration of these medications by a clinical provider in an outpatient facility setting per the provider's contract and applicable medical policies, excluding reimbursement for the drug ingredient cost itself.

Applicable agents include oral phosphate binders listed in Appendix A (e.g., calcium acetate, ferric citrate, lanthanum carbonate, sevelamer carbonate, sevelamer hydrochloride, sucroferric oxyhydroxide).

Coding and Claims Handling

Denied HCPCS Codes (Medical Benefit) for oral phosphate bindersHCPCSNot Covered

J0601	Sevelamer carbonate (Renvela or therapeutically equivalent), oral, 20 mg (for ESRD on dialysis)
J0602	Sevelamer carbonate (Renvela or therapeutically equivalent), oral, powder; 20 mg (for ESRD on dialysis)
J0603	Sevelamer hydrochloride (Renagel or therapeutically equivalent), oral, 20 mg (for ESRD on dialysis)
J0605	Sucroferric oxyhydroxide (Velphoro), oral, 5 mg (for ESRD on dialysis)
J0607	Lanthanum carbonate (Fosrenol), oral, 5 mg (for ESRD on dialysis)
J0608	Lanthanum carbonate (Fosrenol), oral, powder; 5 mg, not therapeutically equivalent to J0607 (for ESRD on dialysis)
J0609	Ferric citrate (Auryxia), oral, 3 mg ferric iron (for ESRD on dialysis)
J0615	Calcium acetate, oral, 23 mg (for ESRD on dialysis)

Pharmacy benefit rules apply

ApplicabilityClaims for these orally administered medications are subject to all pharmacy benefit rules, including formulary status, prior authorization, step therapy, quantity limits, and member cost-sharing (copayment/coinsurance).

Formulary and utilization managementCoverage depends on formulary placement; prior authorization and step therapy requirements may apply per pharmacy policy.

Quantity limitsQuantity limits established under the pharmacy benefit apply to claims for these medications.

Member cost-sharingCopayment or coinsurance under the member's pharmacy benefit applies to these prescriptions.

Pharmacy processing requirementClaims must be processed through the pharmacy benefit to be subject to these rules (not processed as medical benefit drug ingredient charges).

Provider Responsibilities and Billing Instructions

Billing Rule

Prior authorization and billing direction — route medications through pharmacy benefit; do not bill ingredient cost to medical benefit

Oscar Health requires providers to ensure members obtain oral phosphate binders through the member’s pharmacy benefit; facilities may not bill Oscar Health for the ingredient drug cost. Claims submitted with oral phosphate binder HCPCS codes for the drug ingredient will be denied. The Plan will only reimburse medically necessary administration (excluding the ingredient cost) per the provider’s contract.

Members must obtain these medications through Oscar Health’s network pharmacies or designated specialty pharmacy partners.
Facilities should not purchase oral phosphate binders for Oscar Health members through buy-and-bill arrangements.
Claims submitted with oral phosphate binder HCPCS codes will be denied; submit dialysis claims without HCPCS codes for oral phosphate.
The prescribing provider must issue a prescription to a participating pharmacy so the pharmacy can adjudicate through the pharmacy benefit.

Definitions and Coverage Disposition

Applicable medications

Primary agentsOral phosphate binders listed in Appendix A (see Appendix A: Applicable Drugs and Drug Classes).

ScopeAlso applies to other designated self‑administered oral medications included in Appendix A and policy definitions.

SettingApplies when these medications are dispensed or administered in outpatient facility settings, including dialysis centers.

Indication requirementPhosphate binders are covered under the pharmacy benefit when prescribed for an FDA‑approved or compendia‑supported indication.

Coverage disposition

Coverage pathwayIngredient drug cost is covered only when processed and dispensed through a participating pharmacy under the member's pharmacy benefit.

Medical benefit billingFacilities may not bill Oscar Health for the ingredient cost of oral phosphate binders; such medical‑benefit drug ingredient claims will be denied.

Administration reimbursementThe Plan will reimburse medically necessary administration by a clinical provider in an outpatient facility per contract, excluding the drug ingredient cost.

Member procurementMembers must obtain these medications through Oscar Health’s network pharmacies or designated specialty pharmacy partners.