As you may know, the federal 340B Drug Pricing Program allows participating hospitals and other providers to purchase certain covered outpatient drugs or biologicals from manufacturers at discounted prices. In accordance with requirements issued via MassHealth’s recent Managed Care Entity Bulletin 114 and All Provider Bulletin 390, effective July 1, 2024 Point32Health will no longer provide reimbursement for the drugs identified below for Tufts Health Together members when they are purchased through the 340B program.
You will need to use non-340B stock for these drugs. Claims for Tufts Health Together members billed with the modifier UD, which indicates that the drugs were purchased through the 340B Drug Pricing Program, will be denied:
- Abecma (idecabtagene vicleucel)
- Breyanzi (lisocabtagene maraleucel)
- Carvykti (ciltacabtagene autoleucel)
- Hemgenix (etranacogene dezaparvovec)
- Kymriah (tisagenlecleucel)
- Luxturna (voretigene neparvovec)
- Skysona (elivaldogene autotemcel)
- Tecartus (brexucabtagene autoleucel)
- Yescarta (axicabtagene ciloleucel)
- Zolgensma (onasemnogene abeparvovec-xioi)
- Zynteglo (betibeglogene autotemcel)
Important billing guidelines
As indicated in Point32Health’s Drugs and Biologicals Payment Policy, because the above-referenced drugs are part of MassHealth’s Acute Hospital Carve-Out Drug List, they must be submitted as professional claims, separately from any facility claims, for appropriate compensation. Providers are required to include the 11-digit national drug code (NDC) number, corresponding HCPCS code(s), and number of units administered to the member on the claim, along with the following supporting documentation, in accordance with MassHealth MCE Bulletin 42:
- The hospital’s actual acquisition cost of the drug
- Copy of the invoice(s) for the drug from the drug manufacturer, supplier, distributor, or other similar party or agent
- Any additional supporting documentation, as necessary
Claims with supporting documentation cannot be submitted electronically and must be submitted on paper, in accordance with the claim submission requirements found in the Claim Requirements, Coordination of Benefits and Dispute Guidelines chapter of the Tufts Health Public Plans Provider Manual.
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