High-Cost Medication Covered Services. Payer shall pay Facility for high-cost medication that exceed $100.00 per medication per day or three medications that combined exceed $240 per day and are Covered Services on a case-by case basis. High Cost Medication Covered Services must be approved in advance of the Customer’s Admission to Facility. Any high-cost medications that are Covered Services that occur after the Customer’s Admission to Facility shall require prior approval of United before the Customer is discharged from the facility. High cost medications shall be paid at the Average Wholesale Price (AWP) of the drug, minus twenty percent (20%), less any applicable Customer Expenses. The following must be included on the claim: Revenue code 636 Name of medication and NDC# HCPCS code Dosage
