Starting for DOS 4/1/26 and thereafter the following codes will be covered through the patient pharmacy benefit and no longer will be covered under patient medical benefit.
Images via UHC website
For DOS 1/1/26 through 3/1/26- providers can still bill either through medical benefit or pharmacy benefit.
For any DOS April 1st 2026 and thereafter the new company that will manage DME ordering and fulfillment will be Synergy Health.
This change will apply to Medicare Advantage Plans in certain states:
Individual HMO and PPO plans:
Via UHC website
Chronic Special Needs Plans (C-SNP)
Via UHC website
Dual Special Needs Plans (D-SNP):
North Dakota
South Dakota
West Virginia
DME providers would need to join Synapse Health network. Synapse will contact you, however you can also reach out to them via email: JoinOurNetwork@synapsehealth.com
Are you a provider in NJ that accepts NJ Managed Medicaid plans in your practice? Then this blog post is for you!
When: this applies for any services done on/and after Jan 1, 2026.
Who is eligible for reimbursement? Providers that are a member of the Center of International Blood and Marrow Transplant Research patient registry AND the provider must participate in the CMS study related to SCD gene therapies.
3. Which Plans- NJ Managed Medicaid Plans, ex. UHC Community Plan
Billing:
1. Professional Provider must bill on a separate professional claim (HCFA-1500)
2. Facility- drug must not be included on any facility claim, and added to any DRG or APC charges
3. SCD- must not be purchased at 340B program or be dispensed from 340B program inventory
Reimbursement:
4. Claims bust include the corresponding NDC, units, HCPCs and DX codes
Rebursement:
The SCD is reimbursed at an invoice/ acquisition cost- the charges on the professional claim must equal to the Supplier invoice or the drug
If the drug is billed through pharmacy (point of sale), the professional claim will not be reimbursed and will be processed as duplicate
Coding:
Please check out the following links for more coding info of the 2 drugs that fall under this policy:
KR2 Medical Billing 