Not Everyone Bills Medications The Same Way

Our clinical team increases plan savings and improves patient care with True Codes

How an Infusion Medication Is Billed and Where It’s Administered Impact the Cost

Let’s talk about infusions. These are medications that must be administered by a medical professional to treat chronic conditions like Multiple Sclerosis and Crohn’s disease. You may have seen advertisements for medications like Stelara, Remicade, or Ocrevus.

There’s a significant price difference between these drugs when a patient receives treatment at a doctor’s office or infusion center compared to a hospital and HOW it is billed.

Because an infusion drug is not typically self-administered, it can be billed on your medical plan by a hospital, NOT on the pharmacy benefit plan. Drugs billed this way are considered J Code drugs. Essentially, any drugs billed under that designation are going to be more costly.

To explain why, look at it this way. There are two kinds of coding systems in healthcare. Level I codes are used by medical practitioners to bill for claims on medical procedures.

Level II Medical J Code Explained

Then, there’s Level II. This coding system, which is referred to as J Codes”, is used for medical devices, supplies, and drugs when billing for claims to insurance. This means that an infusion drug used in a hospital can be assigned a J Code in order to be billed as a more costly medical claim, rather than a less costly pharmacy claim.

Here’s the problem. You likely didn’t know any of this. There tends to be a lack of transparency when it comes to WHY certain drugs are billed higher than others. To be frank, getting billed under your medical policy for an infusion includes a price mark-up that could be three times higher!

Here’s the good news. There are ways around these markups and it deserves a conversation. True Rx Health Strategists would love to have that conversation with you, and help drive your drug costs down while improving the member experience.

If you’re a health care benefits broker, consultant, or an employer who wants to discuss pharmacy benefit solutions with a strategist, contact us at hello@​truerx.​com to arrange a meeting.