MedicaidCoverageMedium impact
MMP 25-19: Pharmacy Coverage for Outcomes-Based Contracts and Other Select High-Cost Physician-Administered Drugs or Therapies
Michigan Medicaid - MDHHS·MI · Oncology, Hematology, Rheumatology +4 more·Pharmacy
Effective date
Jul 1, 2025
We identified it
Jun 20, 2026
Summary
Starting July 1, 2025, Michigan Medicaid will allow pharmacies to bill for select high-cost physician-administered drugs (including gene therapies) that are part of outcomes-based contracts, rather than providers billing these on professional claims. This creates a new pharmacy billing pathway for specific high-cost injectable drugs and therapies.
Action Required
By July 1, 2025: Michigan providers must identify if they administer high-cost drugs covered by outcomes-based contracts by checking the Select High-Cost Physician-Administered Injectable Drugs list on the MDHHS PBM website. Coordinate with pharmacies to ensure these drugs are billed through pharmacy benefit instead of professional claims. Ensure no duplicate billing occurs - if pharmacy bills the drug, provider cannot also bill for the drug cost. Update billing workflows to prevent duplicate claims submission.