CurrentOscar HealthPolicy N/A

Pharmacy Sourcing for Select Provider-Administered Drugs

Requires participating outpatient providers in specified states to obtain certain provider-administered drugs from the Plan's in-network specialty pharmacies and defines reimbursement conditions when drugs are obtained outside the specialty pharmacy channel.

Policy Summary

PayerOscar Health

PolicyPharmacy Sourcing for Select Provider-Administered Drugs

Policy CodePolicy N/A

Change TypeNew policy

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionParticipating providers must source listed provider-administered drugs from the Plan's in-network specialty pharmacy or obtain authorization from Oscar Health and provide objective evidence of sourcing barriers if requested.

SourceLink

POLICY UPDATE CHANGES

New policy establishing requirements that participating providers source listed provider-administered drugs from the Plan's in-network specialty pharmacies and specifying reimbursement rules.

1new policy created (Origination Date 06/02/2025)

10/01/2025effective date

2states explicitly applicable

~40listed drugs in Appendix

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 and Reimbursement Rules

Coverage criteria and reimbursement rules

Coverage and reimbursement rules when drugs are obtained via the required specialty pharmacy versus non-network sourcing.

Providers must obtain drugs listed in Table 1 from an in-network specialty pharmacy unless Oscar Health authorizes otherwise.

ALL of the following

The specialty pharmacy will bill the Plan directly for the drug under the member's pharmacy benefit.
Providers may seek reimbursement from the Plan ONLY for drug administration services; providers may NOT bill the member for the drug when obtained through the network specialty pharmacy.
Reimbursement for drug administration services is subject to the provider's contract terms and applicable fee schedules.

ALL of the following

Provider claims must include the appropriate administration procedure code and the drug code with a nominal fee of $0.01 for the drug code.
Claims should include necessary processing information such as date of service, procedure codes, diagnosis codes, and National Drug Code (NDC) as applicable.

ALL of the following

Any drugs obtained from a non-network specialty pharmacy without an approved exception will not be reimbursed.
Non-compliance may result in claim denials, recovery of overpayments, audits, and corrective actions per the Plan (including potential contract actions).
Providers are responsible for any costs associated with obtaining drugs from non-authorized sources and may NOT balance-bill members for denied drug charges.

ALL of the following

Providers must administer drugs per FDA-approved labeling and applicable clinical guidelines, monitor and document response and adverse reactions, and promptly notify the Plan and specialty pharmacy of delivery or quality issues, providing objective evidence of sourcing barriers upon request.
The Plan reserves the right to conduct audits and may request additional documentation to support claims; the Plan may update reimbursement guidelines and will notify providers per contract terms.

Applicable Codes and Claiming Details

Select HCPCS codes from AppendixHCPCS

Q5121	Avsola (infliximab-axxq)
J2329	Briumvi (ublituximab-xiiy)
J3247	Cosentyx (secukinumab)
J0178	Eylea (aflibercept)
J0638	Ilaris (canakinumab)
J1745	Remicade (infliximab)
J2778	Lucentis (ranibizumab)
J2777	Vabysmo (faricimab-svoa)

Appendix additional HCPCS entries (context)HCPCS

J0177	Eylea HD (aflibercept)
C9161	Eylea HD - alternate code (aflibercept)
Q5147	Pavblu (aflibercept-ayyh)
J3590	Conexxence / Ospomyv / Stoboclo - denosumab variants (NOC entries)
C9399	Not otherwise classified (NOC) HCPCS code - used with J3590 in Appendix
Q5103	Inflectra (infliximab-dyyb)
Q5102	infliximab (biosimilar)
Q5136	Jubbonti (denosumab-bnht)
J1306	Leqvio (inclisiran)
J2350	Ocrevus (ocrelizumab)

1–10 of 15

1/2

Not otherwise classified (NOC) HCPCS codes noted in AppendixHCPCS

J3590	Listed in Appendix for multiple denosumab products (used when a more specific HCPCS code is not available)
C9399	Used in Appendix alongside J3590 as a NOC indicator

Ophthalmic injection HCPCS codes in AppendixHCPCS

J0178	Eylea (aflibercept)
J0177	Eylea HD (aflibercept)
C9161	Eylea HD alternate code
J2778	Lucentis (ranibizumab)
J2777	Vabysmo (faricimab-svoa)
Q5147	Pavblu (aflibercept-ayyh)

Infliximab and biosimilars HCPCS codes in AppendixHCPCS

Q5121	Avsola (infliximab-axxq)
Q5103	Inflectra (infliximab-dyyb)
Q5102	infliximab (infliximab)
J1745	Remicade (infliximab)
Q5104	Renflexis (infliximab)

Selected monoclonal antibody HCPCS codes in AppendixHCPCS

J2329	Briumvi (ublituximab-xiiy)
J0638	Ilaris (canakinumab)
J2350	Ocrevus (ocrelizumab)
J2351	Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq)
J2323	Tysabri (natalizumab)
J0491	Saphnelo (anifrolumab-fnia)

Cardiovascular and other agents in AppendixHCPCS

J1306	Leqvio (inclisiran)
J0897	Prolia (denosumab)
Q5136	Jubbonti (denosumab-bbdz)

Ophthalmic and specialty biologics (misc) in AppendixHCPCS

J2778	Lucentis (ranibizumab)
J2777	Vabysmo (faricimab-svoa)
J0178	Eylea (aflibercept)

inv-03: Nominal drug fee on provider claim — $0.01 required drug code charge when submitting administration claim

Required nominal drug chargeThe appropriate drug code must be submitted on the provider claim with a nominal fee of $0.01 when submitting the administration claim.

Claim componentsClaims must include the administration code and the drug code (with $0.01 charge), date of service, procedure codes, diagnosis codes, and NDC as applicable.

PurposeNominal drug line enables Plan processing while drug reimbursement is billed by the network specialty pharmacy under the member's pharmacy benefit.

Provider billing restrictionProviders may only seek reimbursement for administration services; they may NOT bill members for the drug when it was obtained through the network specialty pharmacy.

Sourcing Requirement and Exception Handling — Provider Responsibilities

Note

Source listed provider‑administered drugs from in‑network specialty pharmacy; notify Plan and provide evidence for exceptions

Participating providers must obtain the provider‑administered drugs listed in Table 1 from Oscar Health’s in‑network specialty pharmacy unless Oscar Health authorizes otherwise. If there are sourcing issues, providers must promptly notify the Plan and the specialty pharmacy and, upon request, provide objective evidence of sourcing barrier(s).

Obtain applicable drugs from the designated in‑network specialty pharmacy (see Appendix).
Promptly notify the Plan and the specialty pharmacy of any issues with drug delivery, quality or tolerability that may warrant exceptions or changes to treatment.
Provide objective evidence of sourcing barrier(s) upon request to support an exception.

Key Definitions

inv-05: Not otherwise classified (NOC) HCPCS codes

DefinitionNot otherwise classified (NOC) HCPCS codes are used when a more specific HCPCS code is not available.

Subject to changeNOC HCPCS codes may be updated or changed over time; providers should verify current codes prior to claim submission.

Usage guidanceUse NOC HCPCS codes only when no specific HCPCS code exists for the service or drug being billed.