Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 06|05|2012 POLICY LAST REVIEWED: 11|05|2025

OVERVIEW Blue Cross Blue Shield of Rhode Island (BCBSRI) follows CMS regulations regarding payment for discarded drugs. BCBSRI will pay for the discarded amount of a single-use drug/biological product after administering what is reasonable and necessary for the patient's condition. BCBSRI encourages providers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner. Additionally, CMS is requiring an informational only modifier to be used when there is no discarded drugs.

MEDICAL CRITERIA Not applicable.

PRIOR AUTHORIZATION
Not applicable.

POLICY STATEMENT Medicare Advantage and Commercial Products Modifiers required for Single use vial or other single use package. When a provider must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a patient, BCSRI provides payment for the amount of drug or biological discarded, as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.

When processing claims for drugs and biologicals BCBSRI requires providers to use to JW modifier to identify the unused drug or biologicals from single use vials/packages that are appropriately discarded. The JW modifier should be billed on a separate line and will provide payment for the amount of discarded drug or biological.

For example, a single use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and 5 units discarded. The 95-unit dose is billed on one line, while the discarded 5 units may be billed on another line by using the JW modifier. Both line items would be processed for payment.

The JW modifier is only applied to the amount of drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit.

For example, one billing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.

• Multi-use vials are not subject to payment for discarded amounts of drug or biological. Payment Policy | Discarded Drugs/Biologicals

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• The billing of drug waste is appropriate only to a single-use vial or single-use package.
• The provider must make a good-faith effort to schedule patients so that the use of drugs is efficient and medically appropriate (unused portion of a drug package administered to another patient).
• Any waste reimbursed by BCBSRI must not be billed for use on any other patient.
• Coverage does not apply if the provider chooses to purchase larger packages (for a lower per-unit cost) when smaller, more appropriate packaging is available.

Providers who document discarded drugs in the medical record must note the date and time, amount of product used, amount of product wasted, and the reason for the waste.

When there is zero waste from a single dose vial or other single dose package, effective, July 1, 2023, the JZ modifier is required. When processing claims for drugs and biologicals, BCBSRI requires providers to use the JZ modifier to identify that zero amount was discarded/not administered to any patient from the drug or biologicals from single use vials/packages. The JZ modifier is appended to the drugs or biologicals HCPCS code charged.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate member certificate/subscriber agreement for applicable drug/biological coverage/benefits.

BACKGROUND The JW and JZ modifiers are a Healthcare Common Procedure Coding System (HCPCS) Level II modifier used on a claim to report the amount of drug or biological (hereafter referred to as drug) that is discarded and/or used and eligible for payment under the discarded drug policy. The modifiers shall only be used for drugs in single dose or single use packaging.

CODING See above.

RELATED POLICIES Medical Supply Wastage
Coding and Payment Guidelines Modifiers

PUBLISHED Provider Update, November 2025 Provider Update, May 2023 Provider Update, March 2020 Provider Update, April 2018
Provider Update, Aug 2012

REFERENCES https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55932 Billing and Coding: JW and JZ Modifier Billing Guidelines i

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS