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Tuesday, 22 March 2022 00:00

J-codes—Understanding How Some Specialty Medications Are Billed

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Have you heard of J codes?  They are the coding used by doctor’s offices, hospitals and other providers to bill for specialty medications that are usually not taken by mouth, like injectables. They are called “J codes” because of the way they are billed.


The medications dispensed can be expensive as they are often specialty medications, chemotherapy and immunosuppressants. They are billed through the medical plan and not the pharmacy plan, so they can be difficult to identify and address.


There are many solutions for addressing J-codes.


-       If you are a fully-insured client, your carrier has mechanisms in place to identify, reprice, and manage these drugs, as it helps hold down the cost of the medical plan. J-codes have been around for decades, and the insurers’ responses have evolved to address those billing practices.

-       If you have a self funded plan and you use an “integrated administration” platform where a fully insured carrier, like Blue Cross/Blue Shield, United Healthcare, Cigna, Humana, and Aetna, administers your claims, you have the benefit of the platforms that the insurers use to keep their own costs down. They have developed these mechanisms over decades to help control their own costs.

-       If you are on a non-integrated platform with a TPA and perhaps a PBM, then your vendor should be focusing on this.


If you want to understand your options and how your administrator addresses these codes, please reach out to one of our Client Managers.

Read 516 times Last modified on Tuesday, 22 March 2022 00:27
Kristen Russell

Kristen founded Fall River Employee Benefits as the culmination of her insurance industry career as an actuary, underwriting executive & consultant. As an Assistant Vice President at Great-West Healthcare (now part of CIGNA), she managed a $1 Billion block of health insurance. She also worked as a Senior Consultant at Reden & Anders, consulting to insurance companies and large employers throughout the country. Ms. Russell received a Bachelor of Science, Business Administration in Actuarial Science, is a member of the American Academy of Actuaries and achieved Fellowship in the Society of Actuaries through a rigorous nine-year series of exams.

Kristen grew up in Iowa but has lived in Colorado since 1993, currently living near our office in the Lower Highlands neighborhood near downtown Denver.  She enjoys bicycling, hiking, traveling and has a special passion for non-profit volunteering. She is married to an incredibly talented photojournalist, has two adult stepdaughters and an adorable Border Collie/Lab mix named Chaco.