Ilumya — buy and bill, or refer out?

Office-administered and infused products bill under the medical benefit, not the pharmacy benefit. Different form, different queue, different codes — and the first decision is whether the office can carry the drug at all.

Is the office set up for buy and bill?

Carrying the drug means buying it, stocking it and billing it. Most dermatology offices are not set up for it, and the referral path is the normal answer — but it has its own failure mode, which is that a referred start stalls invisibly.

Billing identifiers

1 product populated

10-digit NDC: 47335-177-95
Ordering from the distributor
11-digit NDC: 47335-0177-95
Claim submission — the padded format payers expect
HCPCS J-code: J3245
How the drug is billed on the medical claim
HCPCS descriptor and billing unit: Injection, tildrakizumab-asmn, 1 mg
Units billed must match the descriptor's unit, not the vial
Place of service: Physician office
Plans restrict where the drug may be given
Administration CPT: not in our data — must be sourced
Injection or infusion administration is billed separately from the drug

Verify before you billConfirmed against the binder's own medical-benefit block: 10-digit NDC for ordering 47335-177-95, 11-digit for claim submission 47335-0177-95, HCPCS J3245, descriptor 'Injection, tildrakizumab-asmn, 1 mg', site of service physician office. The administration CPT is still not stated anywhere and is still not to be guessed. Verify every field against the CMS quarterly file before billing.

Answer the question above and the workflow appears here.

Where to get the codes

CMS HCPCS Level II quarterly file — J-codes and descriptors
FDA NDC Directory — 10- and 11-digit ordering NDCs
The manufacturer's own billing and coding guide, per product
The plan's medical policy for site-of-service requirements

Refresh cadenceCMS publishes HCPCS quarterly. Do not reuse last year's J-code — codes are reassigned and descriptors change billing units.

Common failures

Submitting to the pharmacy benefit when the plan requires medical, or the reverse. Costs a full cycle.
Billing units from the vial rather than the descriptor.
Assuming a J-code is stable year to year.
Referring to an infusion center and never confirming receipt.

Coverage of our data

1 of 21 therapies flagged medical benefit. 1 with billing identifiers.

The gap, stated plainlyThis tool is a workflow with one worked example. It becomes operationally useful when someone pulls six fields per medical-benefit product from CMS and the manufacturer billing guides. That is a sourcing task, not a build task.

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