Specialty Drug Reimbursement – Newsletter – November 2019 – Volume 19, Issue 11

INSIDE THIS ISSUE

CMS News


CODE UPDATES

Large Price Changes:

We identify and report on the codes with the most substantial pricing increases or decreases each month and detail the rationale for the change.

Of the 68 AWP Drug Code Price changes this month, 19 (28%) were price decreases. The table in the Drug Reimbursement Code Price Updates section includes all AWP drug Code Price changes for this month. Please note:  These numbers represent AWP Code Price changes only. See below for examples of codes with significant price changes this month.

LOOK UP PRICES NOW:

Price Decreases:

  • J9210 Injection, emapalumab-lzsg, 1 mg 33%
  • J1205 Injection, chlorothiazide sodium, per 500 mg 23%
  • J1165 Injection, phenytoin sodium, per 50 mg 19%

Price Increases:

  • J0698 Cefotaxime sodium, per gram 39%
  • J9209 Injection, mesna, 200 mg 23%
  • Q4195 Puraply, per square centimeter (Code Price is based on median pricing methodology) 20%

CMS News:

New HCPCS® Codes Effective January 1, 2020 Coming Soon

Centers for Medicare and Medicaid (CMS) will soon be releasing New, Deleted, and Revised HCPCS® Codes effective January 1, 2020. Check back in our December newsletter for a list of updates. Customers can expect to see these changes in our December update in order to allow customers to update their systems accordingly before such codes go into effect.

 


DRUG REIMBURSEMENT CODE PRICE UPDATES

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 68 Drug Codes that required a recalculation of their AWP Code Price. Log in to www.ReimbursementCodes.com to view the pricing updates for these codes:

 

90715 J0185 J0878 J2405 J7327 J9210 Q4195
A4216 J0295 J1162 J2860 J7332 J9225 Q4196
A4245 J0364 J1165 J3145 J7507 J9226 S0030
A4253 J0500 J1205 J3245 J8700 J9245 S0117
A4259 J0517 J1301 J3285 J9032 J9307 S0119
A9551 J0642 J1453 J3316 J9036 J9371 S0189
A9556 J0694 J1569 J7178 J9118 Q0138 S5566
A9589 J0698 J1650 J7180 J9201 Q0139 S5571
B4103 J0770 J1980 J7187 J9206 Q0162
B4158 J0775 J2278 J7202 J9209 Q3028

 


DRUGS/DEVICES: NEW/UPDATED BILLING & CLINICAL INFORMATION

As new drugs come to market we review them for possible inclusion in our database. When a new drug is added to the database, we develop detailed clinical and billing information for the drug if appropriate.

During the past month, our review identified two new drugs which needed to be added to our database. Our review of existing drugs in our database with clinical and billing information already assigned identified thirteen drugs that required updating.

New:

XEMBIFY® (immune globulin subcutaneous, human – klhw) 20% solution for subcutaneous injection – by Grifols Therapeutics LLC

BEOVU® (brolucizumab-dbll) injection, for intravitreal injection – by Novartis Pharmaceuticals Corp

 

Updated:

VIMPAT® (lacosamide) injection, for intravenous use, CV – by UCB, Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

RASUVO (methotrexate) injection, for subcutaneous use – by Medac Pharma Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

SILIQ™ (brodalumab) injection, for subcutaneous use – by Valeant Pharmaceuticals North America LLC

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

GANIRELIX ACETATE- ganirelix acetate injection, solution – by Organon USA Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

NOXAFIL® (posaconazole) injection 18 mg/mL – by Merck & Co., Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

ALOPRIM ® (allopurinol sodium) for Injection – by Mylan Institutional LLC

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

SIGNIFOR® (pasireotide) injection, for subcutaneous use – by Novartis Pharmaceuticals Corp.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

VOLUVEN® (6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride injection), for administration by intravenous infusion – by Hospira, Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

THROMBIN-JMI® (Thrombin, Topical (Bovine) U.S.P.), Solution for topical use – by Pfizer

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

THROMBI-GEL® thrombin/gelatin foam hemostat – by Pfizer

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

TACHOSIL® Fibrin Sealant Patch Absorbable Patch for Topical Use – by Baxter Healthcare Corp.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

VARITHENA™ Polidocanol injectable foam – by Biocompatibles UK Ltd

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

ZEJULA® (niraparib) capsules, for oral use – by Tesaro, Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

View last month’s Newsletter


Read white papers, view specialty drug pipeline reviews, and watch webinars:

RJ Health Resource Library

Contact Us

info@ReimbursementCodes.com

Please let us know if you have any questions about the content or functionality of our site. Contact us to request the addition of a code to the site or share your suggestions for enhancements.


RJ Health is a drug data, application & analytics provider to the pharmacy reimbursement market, who brings scalability to specialty drug innovation. We focus on specialty drug innovation (new approvals and additional indications), as well as normalizing reimbursement for drug classifications that have market forces at-play (generics / biosimilars, rebates, and CMS policy). The company provides industry standard pricing, coding, dosing, weight, age, and diagnosis data & analyses to pharmacy, market access, claims, billing, finance, and network management clientele. RJ Health ensures transparency between manufacturer, payor, provider, pharmacies and their respective solution vendors (PBMs, Payment Integrity, Revenue Cycle, EHR, etc…) – all licensees of RJ Health data. 

Our tools and data:

Assist in understanding drug pricing and healthcare reimbursement for drug claims

Enable organizations to look up and crosswalk NDCs and HCPCS codes – J codes, C codes and other

 Assist in calculating drug dosage accurately and ensure claims are reimbursed properly based on unit requirements

Ensure claim accuracy and crosswalk drug codes

Help organizations make the best decisions for drug formularies

Combine clinical diagnosis and procedural coding matched to the right drug and dosage, as well as the most cost-efficient specialty drug price


© 2019 RJ Health Systems International, LLC.  All rights reserved. This newsletter and its contents are copyright protected.  No part of this newsletter may be reproduced in any manner by any means without written permission of RJ Health Systems International, LLC.

CPT copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.