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 criteria Premera uses to apply edits to drugs and biologics administered in physician offices and outpatient facility clinics and governs billing/reimbursement for professional and facility medical claims across Premera and affiliated plans.

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 TypeAdded facility claim editsclarified references

Effective DateClaims DOS on or after 2025-12-05

Next Review Date

Key ActionProviders must bill 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/medications administered in an outpatient facility setting processed under the member's medical benefits effective on claims with dates of service December 5, 2025 and after.

Policy statement clarified to reference additional nationally recognized drug information resources and a References and Resources section.

multipleLines of business

2025-12-05Facility edits start

02/06/26Last review

annualReview cadence

Coverage Criteria and Rules

Coverage criteria and rules

Coverage consideration rules applied by the Plan for administered drugs/biologics:

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

D&B claim edits use criteria established by the U.S. Food and Drug Administration (FDA) as contained in the drug manufacturer’s prescribing information (package insert).

Edits may reference nationally recognized drug information resources (including, but not limited to, Lexicomp/Lexi-Drugs, Micromedex DRUGDEX, Medi-Span, RJ Health, NCCN Drugs and Biologics Compendium) to determine appropriate use and reimbursement.

D&B edits currently apply to drugs/medications administered in a physician office or outpatient clinic and, effective for claims with dates of service December 5, 2025 and after, also apply to drugs/medications administered in an outpatient facility setting processed under the member’s medical benefits.

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 TypeAdded facility claim editsclarified references

Effective DateClaims DOS on or after 2025-12-05

Next Review Date

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

SourceLink

On This Page

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Coding, Effective Dates, and Code Sets

Required coding elements for administered drugsmixedCovered

HCPCS (drug administration series required)	Appropriate HCPCS procedure code for the drug/biologic administered is required on claims.
NDC	Active National Drug Code must be included on the claim for consideration of reimbursement.
Modifiers JW, JZ	JW for drug amount discarded/wasted; JZ for zero drug amount discarded/not administered.

Effective date for facility claim edits

Effective dateClaims with dates of service on or after December 5, 2025

ScopeEdits expanded to apply to drugs/medications administered in outpatient facility settings (in addition to physician office and outpatient clinic settings)

Applicable lines of businessPremera Blue Cross, Premera Blue Cross Blue Shield of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company, and Premera Blue Cross HMO

Billing requirementDrugs/biologics must be billed with an appropriate HCPCS procedure code and an active NDC to be considered for reimbursement

Billing, Documentation, and Modifier Requirements

Documentation Required

Billing and documentation requirements — provider-action

All administered drugs/biologics must be billed with the appropriate HCPCS procedure code and an active National Drug Code (NDC) to be considered for reimbursement. Providers must follow the Plan's Payment Policies (see Cross Reference) for correct NDC billing on professional and outpatient facility claims.

All administered drugs/biologics require an appropriate HCPCS procedure code and an active NDC for reimbursement.
Follow Payment Policies in the Cross Reference for NDC billing on professional and outpatient facility claims.

Billing Rule

Coding/billing rules and modifiers

Use modifier JZ to indicate the administered portion of a single-dose/ single-use vial when no drug wastage occurs; use modifier JW to indicate the discarded/wasted portion of a single-dose/ single-use vial. Follow the Plan's Cross Reference Payment Policies for detailed guidance on coding for administered and wasted portions and for modifier usage. Incorrect modifier or NDC reporting may result in claim denials, audits, or contractual penalties.

Apply JZ when no wastage occurred (administered portion only).
Apply JW to report discarded/wasted drug quantity when applicable.
Refer to Cross Reference Payment Policies for detailed coding and modifier guidance.

Key Definitions

Definition of Drug & Biologic (D&B) claim edits

DefinitionD&B claim edits are automated adjudication rules that use FDA package insert criteria and other nationally recognized drug information sources to determine appropriate use and reimbursement for administered drugs/biologics.

Primary data sourceDrug manufacturer’s prescribing information / FDA package insert (Drugs@FDA)

Additional reference sourcesLexicomp (Lexi-Drugs), Micromedex DRUGDEX, Medi-Span, RJ Health, NCCN Drugs and Biologics Compendium, Elsevier/Gold Standard Clinical Pharmacology, AHFS DI

PurposeTo validate appropriate administration, coding, and reimbursement of drugs/biologics processed under the member's medical benefits

Operational noteEdits are supported by the Plan’s Medical or Pharmacy Policies and implemented by claim editors during adjudication

JW and JZ modifiers — definition and usage for waste reporting

JW modifierUsed to report the drug amount that was discarded/wasted (wasted portion of an administered drug)

JZ modifierUsed to report that zero drug amount was discarded/not administered

Billing guidanceRefer to cross-referenced Payment Policies listed in the Cross Reference/References section for correct coding and use of JW/JZ on professional and outpatient facility claims

Coding contextModifiers apply when coding for administered and wasted portions of a drug to ensure accurate reimbursement handling