Specialty Drug Reimbursement – Newsletter – January 2018 – Volume 18, Issue 01


WEBINAR – February 1st, 2:00PM EST:

Blog Updates:

HCPCS Drug Code Updates:

Drug Reimbursement Code Price Updates


WEBINAR – February 1st, 2:00PM EST

Solving for Incorrectly Mapped NDC to HCPCS/CPT® Codes And Improperly Reported NDC Units:

In discussions with our customers regarding Medical Pharmaceuticals claims, over 30% submitted with an NDC had an incorrectly mapped HCPCS/CPT® Code and/or improperly reported NDC units.
These types of errors may lead to miscalculated reimbursement rates, denied claims and a rise in claim appeals / manual intervention.

NDC Unit Conversion Webinar

Join us on February 1st at 2:00 EST to review some of the root causes of this issue and how our NDC Unit Conversion can be used to identify and correct these claims.



Rituxan (Rituximab) Biosimilars – 2018 Drug Pipeline Review:

2018 Rituxan Biosimilars Pipeline Review

In 2016 Rituxan had over $4 billion in sales in the United States, making it a lucrative area for the development of biosimilars. As of the publication of this article, Rituxan has two biosimilars awaiting FDA review in 2018 and one product in study.

See the executive summary table here.

Trends in FDA approval of Specialty Drugs: 1990 through 2017

FDA Approval of Specialty Drugs: 1990 - 2017

There are several publications on the Food and Drug Administration’s (FDA) activities over time, but specific information on specialty drug approvals and trends since 1990 are difficult to find. Our overall purpose for this blog is to review the history of approvals and trends since 1990 for specialty medically covered drug. Initially, we will provide an overview of drug approvals regardless of the potential benefit of coverage, but will subsequently focus on drugs covered only under the medical benefit.

Continue reading here.


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 64 AWP Drug Code Price changes this month, 21 (33%) were price decreases. The table in the Drug Reimbursement Code Price Updates section includes all AWP drug Code Price changes for this month. See below for examples of codes with significant price changes this month.

Price Decreases:

J0637 Injection, caspofungin acetate, 5 mg

        •  Decrease of 34% due to 1 new generic NDC entering market

J7316  Injection, ocriplasmin, 0.125 mg

        •  Decrease of 30% due to decrease by manufacturer (Thrombogenics)

S0020 Injection, bupivacaine hydrochloride, 30 mL

        •  Decrease of 29% due to inactivation of 2 generic NDCs

Price Increases:

S0077 Injection, clindamycin phosphate, 300 mg

        •  Increase of 83% due to 6 new generic NDCs entering market

J2210 Injection, methylergonovine maleate, up to 0.2 mg

        •  Increase of 41% due to increase for 2 generic NDCs

J1040 Injection, methylprednisolone acetate, 80 mg

        •  Increase of 22% due to increase for 3 generic NDCs

Reminder – New HCPCS Drug Codes for 2018:

CMS (Centers for Medicare & Medicaid Services) has released the annual Alpha-Numeric HCPCS File for 2018. ReimbursementCodes.com has added the following new HCPCS Drug Codes to our database. These new Drug Codes became effective for Medicare billing for dates of service on or after January 1, 2018.

Please note: This is not a complete list of all 2018 HCPCS NEW Codes, but includes all codes for drugs that would appear on the ReimbursementCodes.com website.

C9014 Injection, cerliponase alfa, 1 mg

C9015 Injection, C-1 esterase inhibitor (human), Haegarda, 10 units

C9016 Injection, triptorelin extended release, 3.75 mg

C9024 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine

C9028 Injection, inotuzumab ozogamicin, 0.1 mg

C9029 Injection, guselkumab, 1 mg

J0565 Injection, bezlotoxumab, 10 mg

J0604 Cinacalcet, oral, 1 mg, (for ESRD on dialysis)

J0606 Injection, etelcalcetide, 0.1 mg

J1428 Injection, eteplirsen, 10 mg

J1555 Injection, immune globulin (Cuvitru), 100 mg

J1627 Injection, granisetron, extended-release, 0.1 mg

J1726 Injection, hydroxyprogesterone caproate, (Makena), 10 mg

J1729 Injection, hydroxyprogesterone caproate, Not Otherwise Specified, 10 mg

J2326 Injection, nusinersen, 0.1 mg

J2350 Injection, ocrelizumab, 1 mg

J3358 Ustekinumab, for intravenous injection, 1 mg

J7210 Injection, factor VIII, (antihemophilic factor, recombinant), (Afstyla), 1 IU

J7211 Injection, factor VIII, (antihemophilic factor, recombinant), (Kovaltry), 1 IU

J7296 Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg

J7345 Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg

J9022 Injection, atezolizumab, 10 mg

J9023 Injection, avelumab, 10 mg

J9203 Injection, gemtuzumab ozogamicin, 0.1 mg

J9285 Injection, olaratumab, 10 mg

Q2040 Tisagenlecleucel, up to 250 million car-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion

Q4176 NeoPatch, per square centimeter

Q4177 FlowerAmnioFlo, 0.1 cc

Q4178 FlowerAmnioPatch, per square centimeter

Q4179 FlowerDerm, per square centimeter

Q4180 Revita, per square centimeter

Q4181 Amnio wound, per square centimeter

Q4182 Transcyte, per square centimeter

Reminder – NEW CPT® Vaccine Code for 2018:

The AMA (American Medical Association) has created the following NEW CPT® Vaccine code effective January 1, 2018.

90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use

Reminder – Code Description Changes for HCPCS Drug/Product Codes for 2018:

CMS has made changes to several HCPCS Drug Code long descriptions effective January 1, 2018.

Listed below are the old and new HCPCS drug/product code descriptions effective for January 1, 2018. You are able to view both descriptions for these HCPCS drug codes on the ReimbursementCodes.com website.

Please note: This is not a complete list of all 2018 HCPCS code description changes, but includes all code description changes for drugs/products that would appear on the ReimbursementCodes.com website.


      New: Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose

      Old: Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose


      New: Grafix Core and GrafixPL Core, per square centimeter

      Old: Grafix Core, per square centimeter


      New: Grafix Prime and GrafixPL Prime, per square centimeter

      Old: Grafix Prime, per square centimeter


      New: NEOX Cord 1K, NEOX Cord RT, or CLARIX Cord 1K, per square centimeter

      Old: NEOX 1K, per square centimeter


      New: NEOX 100 or CLARIX 100, per square centimeter

      Old: NEOX 100, per square centimeter


      New: Kerecis Omega3, per square centimeter

      Old: Marigen, per square centimeter

      Please note: This Code Description change is due to a product name change.


      New: Woundex Flow, BioSkin Flow 0.5 cc

      Old: AmnioPro Flow, BioSkin Flow, BioRenew Flow, Woundex Flow, Amniogen-A, AmnioGen-C, 0.5 cc


      New: Woundex, BioSkin, per square centimeter

      Old: AmnioPro, BioSkin, BioRenew, Woundex, Amniogen-45, AmnioGen-200, per square centimeter

Reminder – 2018 Deleted HCPCS Drug Codes:

Effective December 31, 2017 the following HCPCS Drug Codes were deleted by CMS (Centers for Medicare & Medicaid Services).

Please note: This is not a complete list of all 2018 HCPCS Deleted Codes, but includes all codes for drugs that would appear on the ReimbursementCodes.com website.

A9599 Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose, not otherwise specified

C9140 Injection, factor VIII (antihemophilic factor, recombinant) (Afstyla), 1 IU

C9483 Injection, atezolizumab, 10 mg

C9484 Injection, eteplirsen, 10 mg

C9485 Injection, olaratumab, 10 mg

C9486 Injection, granisetron extended release, 0.1 mg

C9489 Injection, nusinersen, 0.1 mg

C9490 Injection, bezlotoxumab, 10 mg

C9491 Injection, avelumab, 10 mg

C9494 Injection, ocrelizumab, 1 mg

J1725 Injection, hydroxyprogesterone caproate, 1 mg

J9300 Injection, gemtuzumab ozogamicin, 5 mg

Q9984 Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg

Q9985 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg

Q9986 Injection, hydroxyprogesterone caproate, (Makena), 10 mg

Q9989 Ustekinumab, for intravenous injection, 1 mg

J7345 Code Price and Billable Unit Change:

Effective with our January 1, 2018 update we have changed the Code Price and billable units for J7345 Aminolevulinic acid HCl for topical administration, 10% gel, 10 mg.

Prior to 1/1/18 the Code Price and billable units were based on 10 mg of the active ingredient of Ameluz. Based on information we received from the manufacturer we have changed the Code Price and billable units to reflect 10 mg of the gel. One tube of Ameluz contains a total of 2 grams (2,000 mg) of gel. We have also updated the code description note to read (Code Price is per 10 mg of gel, tube contains total of 2g (2,000 mg) gel).

Please note: J7345 did not become effective for Medicare billing until January 1, 2018.


This month, during our review of the 2976 Reimbursement HCPCS/CPT® Codes in our system, we identified 64 Drug Codes that required a recalculation of their AWP Code Price. There are pricing updates for the following codes:

86580 B4162 J1631 J8655
90621 C9250 J1800 J8670
90670 J0180 J1833 J9120
90675 J0221 J1885 J9171
90682 J0289 J2210 J9185
90690 J0594 J2250 J9190
90691 J0637 J2425 J9351
90698 J0694 J2920 Q4074
90702 J0894 J2930 Q4138
90713 J1030 J3243 Q4160
90734 J1040 J7030 S0020
90738 J1071 J7175 S0032
A4245 J1110 J7316 S0077
A4253 J1200 J7345 S0090
A4614 J1439 J7508 S4991
B4157 J1557 J7525 S8490

To view the pricing updates for the above codes please log into:



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 seven 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 three drugs that required updating.


BORTEZOMIB for injection, for intravenous useby Fresenius-Kabi

CINVANTI™ (aprepitant) injectable emulsion, for intravenous useby Heron Therapeutics

HEMLIBRA® (emicizumab-kxwh) Injection, for subcutaneous useby Genentech (NOC

MEPSEVII™ (vestronidase alfa-vjbk) injection, for intravenous useby Ultragenyx Pharmaceutical

OZEMPIC® (semaglutide) injection, for subcutaneous useby Novo Nordisk

PREVYMIS™ (letermovir) injection, for intravenous useby Merck

REBINYN® (Coagulation Factor IX (Recombinant), GlycoPEGylated) lyophilized powder for solution for intravenous injectionby Novo Nordisk


BOSULIF® (bosutinib) tablets, for oral useby Pfizer

      • Indications & Usage, Dosage & Administration and Warnings & Precautions

CABOMETYX® (cabozantinib) tablets, for oral useby Exelixis

      • Indications & Usage, Warnings & Precautions

TALTZ® (ixekizumab) injection, for subcutaneous useby Eli Lilly and Company

      • Indications & Usage, Dosage & Administration and Warnings & Precautions



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