CO · guidance
CO HCPF Physician-Administered Drugs (PAD) Billing Manual — Pharmacy Billing Requirements
PharmacyBillingRequirements
Insomeinstances,apharmacymayneedtodispensePADs.ForanyPADwhichwillbeadministeredbyahealthcareprofessionalinthehomeoratalong-termcarefacility,thepharmacymustbillthepharmacybenefitmanager(PBM).Thisprocessmayrequiretheappropriateplaceofservicebillingcodeand/orapriorauthorization.VisitthePharmacyResourceswebpageforallpharmacybillingpoliciesandguidance.
MedicarePartBCrossoverclaimsforPADswithinspecificdrugclassesnotdispensed"incidentto"aphysicianservicemaybebilledbythepharmacytothemedicalbenefit.ThedispensingpharmacymustbeenrolledasaHealthFirstColoradoproviderunderthePharmacyProviderType(PT)09withDurableMedicalEquipment(DME)ProviderSpecialty(PS)462andbillthemedicalbenefitSupplycontract.Suchdrugclassesincludeimmunosuppressivedrugs,oralanti-emeticdrugs,oralanti-cancerdrugs,anddrugsself-administeredthroughanypieceofdurablemedicalequipment.Insuchcases,thepharmacymustbillMedicarePartBasprimarycoverageandHealthFirstColoradoassecondary.
AnyPADdispensed"incidentto"aphysicianservicecannotbebilledbyapharmacy.Thedrugmustbepurchasedbythephysician'sofficeorclinicandbilledthroughthestandardbuyandbillprocess.GuidelinesforhowPADsaretobebilledhavebeenestablishedin10CCR2505-10,Section8.800.5.
Processesknownas"white-bagging"and"brown-bagging"wherePADsarebilledtothePharmacyBenefitandadministeredintheofficeorclinicarenotusuallyallowed."White-bagging"isdefinedasthedistributionofpatient-specificdrugfromapharmacytoamedicalprovider'soffice,clinicorhospitalforadministration."Brown-bagging"iswhenapharmacydispensesamedicationdirectlytothemember,whothentransportsthedrugtotheprovider'soffice,clinicorhospitalforadministration.
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TheremaybesomeinstanceswhereapharmacistcanadministeraPADorspecificimmunizationstoaHealthFirstColoradomemberinthepharmacy.
EffectiveNovember1,2018,pharmacistsmayenrollasaproviderwiththeDepartmentandonceenrolledcanadministerspecificvaccinationsinthepharmacy.Pharmacistsmust:
FollowtheBoardofPharmacyRulesoutlinedin3CCR719-1,19.00.00.
RendervaccinationsconsistentwithpolicyandthePharmacistVaccinationlistpostedintheImmunizationsBillingManual.
BilltheMedicalBenefitforthevaccinationprocedurecodeandappropriateadministrationcode.
EffectiveJanuary1,2019,theDepartmentimplementedHB18-1007,whichstipulatesthatifapharmacyhasenteredintoacollaborativepracticeagreementwithoneormorephysiciansforthepurposesofadministeringVivitrol,thatthepharmacywheretheinjectionisadministeredshallreceivereimbursementwhenanenrolledpharmacistadministersthePADinthepharmacy.
InaccordancewithHouseBill21-1275andeffectiveJanuary14,2022,noplaceofservicepriorauthorizationisrequiredforextended-releaseinjectablemedications(LAIs)usedforthetreatmentofmentalhealthorsubstanceusedisorders(SUD),whenadministeredbyahealthcareprofessionalandbilledunderthePharmacyBenefit.Inaddition,LAIsmaybeadministeredinanysetting(pharmacy,clinic,medicalofficeormemberhome)andbilledtothePharmacyorMedicalBenefitasmostappropriateandinaccordancewithallHealthFirstColoradobillingpolicies.
RefertothePharmacistServicesBillingManualforadditionalinformation.
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PharmacyprovidersdispensinganyDMEPOScoveredservicesmustbillaccordingtotheDMEPOSBenefitpoliciesandproceduresoutlinedintheDMEPOSBillingManual.
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Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
989aaed40a9fecbaaaab5d5bc0cc869a47eb6d726c66f4860b8ff745d5fb3e8c
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