Specialty Drug Reimbursement – Newsletter – February 2018 – Volume 18, Issue 02



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

Blog Updates:

        •  Hemlibra Introductory Pricing


        •  New/Updated Billing and Clinical Information

Code Updates:

        •  Large Price Changes
        •  HCPCS/CPT Codes With Price Changes
        •  Reminder – New HCPCS Drug Codes for 2018



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

View the webinar recording 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.



Hemlibra Introductory Pricing

Hemlibra Introductory Pricing

What value did the manufacturer place on bleed prevention with Hemlibra (emicizumab-kxwh) versus on-demand treatment with current bypassing agents?

After viewing one emicizumab treatment cost estimate of $500,000 annually, we wanted to ascertain the accuracy of that estimate in addition to estimating if savings from reduced bypassing agent requirement would exceed the cost of emicizumab.

Read on for everything you need to know about Hemlibra introductory pricing 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 209 AWP Drug Code Price changes this month, 12 (6%) 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:

C9250   Human plasma fibrin sealant, vapor-heated, solvent-detergent (Artiss), 2 mL

        •  Decrease of 50% due to new lower cost brand NDC entering market

J7188   Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU

        •  Decrease of 43% due to decrease by manufacturer (Baxalta)

A4250  Urine test or reagent strips or tablets (100 tablets or strips)

        •  Decrease of 41% due to inactivation of 15 NDCs


Price Increases:

J7510   Prednisolone, oral, per 5 mg

        •  Increase of 77% due to increase for lowest brand NDC

J2175   Injection, meperidine hydrochloride, per 100 mg

        •  Increase of 76% due to increase for 2 generic NDCs

Q4158   Kerecis Omega3, per square centimeter

        •  Increase of 55% due to increase by manufacturer (Kerecis Limited)



This month, during our review of the 2976 Reimbursement HCPCS/CPT® Codes in our system, we identified 209 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.

90396 C9356 J0897 J1980 J3250 J8565 J9308
90620 C9363 J1000 J2150 J3262 J8650 J9310
90632 C9497 J1020 J2170 J3301 J9000 J9325
90633 J0129 J1050 J2175 J3357 J9015 J9328
90636 J0130 J1250 J2182 J3360 J9017 J9330
90648 J0135 J1265 J2250 J3380 J9022 J9354
90670 J0202 J1290 J2270 J3471 J9027 J9355
90675 J0256 J1335 J2278 J3486 J9032 Q0138
90681 J0257 J1364 J2300 J7042 J9033 Q0139
90696 J0270 J1410 J2323 J7050 J9035 Q3027
90700 J0280 J1438 J2353 J7060 J9039 Q4104
90715 J0287 J1455 J2426 J7070 J9042 Q4105
90723 J0401 J1555 J2502 J7120 J9055 Q4108
90746 J0461 J1569 J2504 J7121 J9060 Q4114
90747 J0480 J1571 J2505 J7188 J9176 Q4131
A4217 J0558 J1573 J2507 J7200 J9179 Q4158
A4250 J0561 J1575 J2543 J7207 J9205 S0017
A6010 J0572 J1626 J2562 J7211 J9214 S0032
A6011 J0574 J1640 J2690 J7296 J9216 S0104
A6248 J0575 J1720 J2792 J7298 J9230 S0122
A7005 J0583 J1726 J2794 J7301 J9245 S0126
A9584 J0594 J1744 J2796 J7303 J9262 S0128
A9586 J0670 J1750 J2860 J7503 J9285 S0137
B4153 J0695 J1817 J2941 J7504 J9295 S0145
C9029 J0702 J1826 J2997 J7510 J9301 S0157
C9250 J0712 J1830 J3030 J7527 J9302 S0182
C9254 J0714 J1885 J3090 J7606 J9303 S4991
C9257 J0716 J1930 J3095 J7639 J9305 S5010
C9285 J0717 J1942 J3101 J7686 J9306 S5553
C9353 J0800 J1950 J3110 J8540 J9307



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 five 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 eight drugs that required updating.


ADMELOG® (insulin lispro injection), for subcutaneous or intravenous use – by Sanofi-Aventis

FIBRYGA®, Fibrinogen Concentrate (Human) Lyophilized Powder for Reconstitution – by Octapharma USA, Inc

KEDRAB Rabies Immune Globulin (Human) Solution for intramuscular injection – by Kedrion Biopharma, Inc.

LUXTURNA™ (voretigene neparvovec-rzyl) intraocular suspension for subretinal injection – by Spark Therapeutics, Inc

SUBLOCADE™ (buprenorphine extended-release) injection, for subcutaneous use – by Indivior



GILOTRIF® (afatinib) tablets, for oral use – by Boehringer Ingelheim

        •  Indications & Usage and Dosage & Administration

LYNPARZA® (olaparib) tablets, for oral use – by Astra Zeneca

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

POMALYST® (pomalidomide) capsules, for oral use – by Celgene Corporation

        •  Warnings & Precautions

REPATHA® (evolocumab) injection, for subcutaneous use – by Amgen

        •  Indications & Usage

REVLIMID® (lenalidomide) capsules, for oral use – by Celgene Corporation

        •  Warnings & Precautions

TASIGNA® (nilotinib) capsules, for oral use – by Novartis

        •  Dosage & Administration and Warnings & Precautions

VENCLEXTA™ (venetoclax) tablets, for oral use – by Abbvie

        •  Dosage & Administration

ZYKADIA® (ceritinib) capsules, for oral use – by Novartis

        •  Dosage & Administration and Warnings & Precautions




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