Reconsideration of Unlisted Code Allowances

Unlisted drug codes, such as J3490, should only be submitted if there is no other code that describes the drug. All unlisted drugs must be submitted with a narrative, dosage and NDC.  

There may be times when the invoice cost of the drug is significantly higher than BCBSNE’s allowance. In such cases, the provider may submit a reconsideration for additional reimbursement using the reconsideration process described in the In-network Health Care Professionals and Facilities General Policies and Procedures Manual, Section 12, Member Benefit Appeal and Reconsideration.  

To facilitate this review, the drug invoice must be submitted with the reconsideration form. Additional reimbursement will not be considered without the invoice. BCBSNE reserves the right to determine a cost threshold for any requested reconsiderations that is cost-efficient for providers and members. Effective June 1, 2019, the threshold for each calendar year is $25.00 based on current costs of claims handling.