Module 5: Reimbursement
CMS Guidance for Oral Antivirals
- Oral antivirals for COVID-19 that meet the statutory requirements at section 1860D-2(e) of the Social Security Act and are not otherwise excluded from coverage must be covered by Part D plans, either as a formulary product or through the formulary exception process consistent with 42 CFR § 423.578(b).
- Consistent with the November 4, 2022, memorandum CMS continues to encourage Part D sponsors to add at least one oral antiviral for COVID-19 that meets the definition of a Part D drug to their Contract Year (CY) 2024 formulary on a preferred or $0 cost-sharing tier, as available in the plan benefit structure.
CMS Commercial COVID-19 oral antivirals memo
CMS Resources: Veklury Billing
- CMS created HCPCS (Healthcare Common Procedure Coding System) code J0248 fo Veklury
- J0248 represents 1mg, and you should report units to reflect the dosage you administered for each patient.
- Outpatient Billing Example: a provider administering Veklury (remdesivir) in the outpatient setting would bill J0248 for the product and could use the following CPT code for its administration:
- 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour)
- and if needed use: 96366 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure).
- Medicare Part B will provide payment for the drug and its administration under the applicable Medicare Part B payment policy when you provide it in the outpatient setting, according to the FDA approval and authorization. In most cases, your patient's yearly Part B deductible and 20% co-insurance apply.
- CMS COVID-19 FAQs Veklury FAQs begin on page 146
CMS Resources
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