September 01, 2022

New York Medicaid: 'By report' billing required for ZOLADEX

Effective Oct. 1, 2021, TerSera Therapeutics LLC., voluntarily withdrew from participation in the Medicaid Drug Rebate Program. As a result, New York State Medicaid fee-for-service (NYS FFS) and UnitedHealthcare Community Plan no longer cover most drugs manufactured by TerSera Therapeutics, LLC. 

What this means for you
As of April 14, 2022, you’ll need to follow the "by report" billing process for ZOLADEX®, a drug manufactured by TerSera.

“By report” billing is used for a service, procedure or drug that is rarely provided, unusual or may require a special report to determine medical appropriateness, as indicated by the “BR” in the fee schedule. Information should include: 

  • An adequate definition of the nature, extent and need for the service/procedure/drug
  • The time, effort and equipment necessary to provide the service/procedure/drug

Additional details may include: 

  • Complexity of symptoms
  • Final diagnosis
  • Pertinent physical findings (such as size, locations and number of lesion(s), if appropriate) 
  • Diagnostic and therapeutic procedures (including major supplementary surgical procedures, if appropriate)
  • Concurrent problems
  • Details about follow-up care

Appropriate documentation (e.g., procedure descriptions, itemized invoices, etc.) should accompany all claims. 

Please note that NYS FFS will review all claims for ZOLADEX. 

Questions?

PCA-1-22-02426-C&S-News
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