CurrentPremera BluecrossPolicy CP.PP.410.v1.4

Drug and Biologic Edits for Drugs Administered in a Physician Office or in an Outpatient Facility Clinic.

Defines the Plan's criteria and claim edits for drugs and biologics administered in physician offices or outpatient facility clinics and billed to medical benefits; applies to Premera Blue Cross and affiliated lines of business.

Policy Summary

PayerPremera Bluecross

PolicyDrug and Biologic Edits for Drugs Administered in a Physician Office or in an Outpatient Facility Clinic.

Policy CodePolicy CP.PP.410.v1.4

Change TypeExpanded application to facility claims; resource updates

Effective DateDecember 5, 2025 (facility edits)

Next Review Date

Key ActionBill all administered drugs/biologics with an appropriate HCPCS procedure code and an active NDC to be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

D&B claim edits will be applied to drugs administered in an outpatient facility setting processed under medical benefits effective on claims with dates of service December 5, 2025 and after.

Revised Policy Title and statement to include D&B edits being applied to facility claims.

Added National Drug Codes List to References and Resources.

Clarified that edits use FDA package insert criteria and other nationally recognized drug information sources to determine appropriate use.

02/06/26Most recent approval/review date

12/05/25Effective DOS for facility claim edits

CP.PP.410.v1.4Policy identifier

Premera+affiliatesScope - lines of business

Coverage Criteria for Administered Drugs and Biologics

Coverage criteria for administered drugs/biologics

Claims for administered drugs/biologics will be subject to automated edits that reference FDA-approved labeling and other nationally recognized drug information sources; reimbursement requires correct coding and adherence to modifier guidance.

Drug/biologic must be administered by a qualified healthcare professional and billed under the member's medical benefits.

Claims must include an appropriate HCPCS procedure code and an active National Drug Code (NDC) to be considered for reimbursement.

Edits reference the drug manufacturer's FDA-approved prescribing information (package insert) and may utilize nationally recognized sources such as Lexicomp, Micromedex DRUGDEX, Medi-Span, RJ Health and others to determine appropriate use.

Edits are applied to drugs/medications administered in a physician office or outpatient clinic; effective for dates of service December 5, 2025 and after, edits will also be applied to drugs administered in an outpatient facility setting.

Policy Summary

PayerPremera Bluecross

PolicyDrug and Biologic Edits for Drugs Administered in a Physician Office or in an Outpatient Facility Clinic.

Policy CodePolicy CP.PP.410.v1.4

Change TypeExpanded application to facility claims; resource updates

Effective DateDecember 5, 2025 (facility edits)

Next Review Date

Key ActionBill all administered drugs/biologics with an appropriate HCPCS procedure code and an active NDC to be considered for reimbursement.

SourceLink

On This Page

Required Coding Elements and Claim Processing Thresholds

Required coding elementsmixedCovered

HCPCS	Appropriate HCPCS procedure code required for administered drug/biologic
NDC	Active National Drug Code required on claim
Modifiers JW/JZ	JW for discarded amount; JZ for zero drug amount discarded

Claim processing threshold — edits applied to professional and outpatient facility claims

Scope of editsD&B claim edits applied to drugs/medications administered by a physician or qualified healthcare professional in a provider office or outpatient clinic and processed under the member's medical benefits.

Facility claims effective dateEdits will also be applied to drugs administered in an outpatient facility setting effective on claims with dates of service December 5, 2025 and after.

Lines of businessApplies to Premera Blue Cross, Premera Blue Cross Blue Shield of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company and Premera Blue Cross HMO lines of business and products.

Billing and Documentation Requirements for Providers

Billing Rule

Billing requirements for administered drugs

All administered drugs/biologics must be billed with an appropriate HCPCS procedure code for the drug/biologic administered and an active National Drug Code (NDC) number to be considered for reimbursement. Providers must follow applicable Payment Policies (see Cross Reference) for correct NDC billing on professional and outpatient facility claims and for correct coding of administered and wasted drug portions using modifiers JZ (no wastage) and JW (wastage) as applicable. Claims that do not include a valid HCPCS code and an active NDC may be denied.

Effective for facility outpatient claims with dates of service on/after 2025-12-05 edits will apply to outpatient facility administered drugs (Chunk 1).
Use FDA package insert and nationally recognized drug information sources (e.g., Lexicomp, Micromedex DRUGDEX, Medi-Span, AHFS DI, NCCN) to support appropriate drug use and coding (Chunk 1 & 2).
Violations may result in increased auditing, penalties, or contract actions per plan (Chunk 2).

Definitions

D&B edits — Drug and Biologic (D&B) claim edits definition

DefinitionDrug and Biologic (D&B) claim edits are automated claim-editor edits that validate administered drugs/biologics against FDA-approved prescribing information and other nationally recognized drug information sources.

Sources used by editsFDA package inserts (Drugs@FDA), Lexicomp/Lexi-Drugs, Micromedex DRUGDEX, Medi-Span, RJ Health and other national sources.

PurposeTo determine appropriate use of administered drugs/biologics billed to medical benefits and to inform reimbursement decisions.

JW / JZ modifiers — wastage reporting

JW modifierModifier JW — reports the drug amount discarded/not administered to any patient (used to code wasted portion).

JZ modifierModifier JZ — reports zero drug amount discarded/not administered to any patient.

Related guidanceSee National Drug Code (NDC) Billing Guidelines and cross-referenced policy for instructions on billing administered and wasted portions using JW/JZ.