Frequently asked questions

This is dependent on the method of administration of the drug and the payer. Drugs that are injected or infused in a medical setting (like a doctor's office or an outpatient hospital facility) are typically billed under the medical benefit. Practices should run a benefit verification to clarify a patient's insurance structure and design when it comes to specialty medications.

While both forms are used for outpatient billing claims, CMS-1500 is generally used for HCP billing and CMS-1450 (UB-04) is used for hospital billing. Please check with the payer (insurance company) reimbursing the service to determine the appropriate form. It is the sole responsibility of the health care provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.

Supplemental plans can vary greatly in cost and what they cover. Patients will want to carefully evaluate the best coverage for them, based on their medical needs and budget.

There are various codes that may be used for a drug. It is the sole responsibility of the health care provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient. You can refer to your organization's guidelines and visit the "Billing and coding" section of this website to learn more.

Using buy-and-bill may result in a lower out-of-pocket cost compared to using a specialty pharmacy. However, coverage, reimbursement, and patient costs may vary significantly by payer, plan, patient, and setting of care. You can learn more about cost in the "How specialty drugs are acquired" section of this website. Practices should run a benefit verification to clarify a patient's insurance structure and design when it comes to specialty medications.