Reminder about Drugs Administered by Injection or Infusion

This is a reminder that not all drugs administered by injection or infusion are covered in the Physicians Drug Program (PDP) as a part of the medical benefit. Some of these drugs are only covered in the outpatient pharmacy benefit when requested by prior authorization (PA) and dispensed by a retail or specialty pharmacy. If the drug is not listed on the PDP Fee Schedule, then the drug is not covered in the PDP and medical benefit, and medical claims submitted for these drugs will be denied.  

Drugs listed on the PDP fee schedule will be paid only when submitted on a medical CMS 1500/UB-04 claim. The medical provider may bill for the drug product and the administration of the drug in such instances.

Drugs covered only in the pharmacy benefit will be paid only when submitted as a pharmacy point-of-sale claim and when applicable PA criteria has been met. In these cases, physicians’ offices should only bill Medicaid for the administration of the drug product.

Drugs administered by injection or infusion which are currently covered only in the outpatient pharmacy benefit include:

Benlysta

Dupixent

Exondys 51

Fasenra

Haegarda

Kevzara

Nucala

Ocrevus

Renflexis

Xolair

Neuromuscular blocking agents such as (Botox, Dysport, Myobloc and Xeomin) are covered under both the outpatient pharmacy benefit and the PDP. However, the outpatient pharmacy benefit requires PA for all FDA approved indications; the PDP covers these agents for all indications except migraine and urinary incontinence therapy.