Separate Reimbursement of Certain Inpatient High-Cost Drug and Biologics

Date: 05/19/25

While Medicaid covers drugs and biologics administered in both inpatient and outpatient settings, those administered in an inpatient setting are usually not reimbursed separately to hospitals. Instead, they are bundled into a Diagnosis Related Group (DRG) payment reflecting all average hospital costs associated with providing care for the patient’s primary diagnosis and complications. DRG payments exclude separate reimbursement for high-cost drugs or biologics, which can range from hundreds of thousands of dollars to upwards of three million dollars per dose.

Effective June 2, 2025, Superior HealthPlan will have a change in reimbursement for the following High-Cost Clinician-Administered Drugs (HCCAD). HCCAD are drugs or biologics that HHSC has approved to be “carved out” of the All-Patient Refined Diagnosis Related Group (APR-DRG) and can be billed on an outpatient claim.

This change will take effect uniformly in both fee-for-service and managed care on June 2, 2025.

The following is a list of drugs impacted by the change:

ABECMA	LYGENIA
BREYANZI	ROCTAVIAN
CARVYKTI	SKYSONA
CASGEVY	TECARTUS
ELEVIDYS	YESCARTA
HEMGENIX	ZOLGENSMA
KYMRIAH	ZYNTEGLO

The HCCADs list and the policies will be published in the June publication of the Outpatient Drug Services Handbook within Texas Medicaid Provider Procedures Manual (TMPPM).