Specialty Drug Reimbursement – Newsletter – March 2018 – Volume 18, Issue 03


Code Updates:

        • Large Price Changes
        • New HCPCS C-Codes Effective April 1, 2018
        • New HCPCS Q-Codes Effective April 1, 2018
        • HCPCS Q-Code Description Change Effective April 1, 2018
        • Deleted HCPCS Q-Code Effective April 1, 2018

CMS News:

        • Part B Biosimilar Biological Product Payment Effective April 1, 2018
        • Implementation of the Transitional Drug Add-On Payment Adjustment – Parsabiv and Sensipar

Drug Reimbursement Code Price Updates


        •New/Updated Billing and Clinical Information




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 58 AWP Drug Code Price changes this month, 15 (26%) 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:

 J0500   Injection, dicyclomine HCl, up to 20mg

        • Decrease of 28% due to decrease for 2 generic NDCs

J1953   Injection, levetiracetam, 10 mg

        • Decrease of 14% due to 2 new generic NDCs entering market

J9000  Injection, doxorubicin hydrochloride, 10 mg

        • Decrease of 13% due to inactivation of 6 generic NDCs


 Price Increases:

 A9505  Thallium Tl-201 thallous chloride, diagnostic, per millicurie

        • Increase of 375% due to inactivation of lowest brand NDC

Q9963   High osmolar contrast material, 350-399 mg/mL iodine concentration, per mL

        • Increase of 187% due to inactivation of lowest brand NDC

S0078   Injection, fosphenytoin sodium, 750 mg

        • Increase of 159% due to re-activation of 2 generic NDCs



New HCPCS Drug C-Codes Effective April 1, 2018:

CMS created 8 new HCPCS drug C-codes effective April 1, 2018 for Medicare’s Hospital OPPS (Outpatient Prospective Payment System) billing. These new C-Codes were released by CMS after we performed our March update. These new codes will appear with our April 1, 2018 update.

C9462 Injection, delafloxacin, 1 mg

C9463 Injection, aprepitant, 1 mg

C9464 Injection, rolapitant, 0.5 mg

C9465 Hyaluronan or derivative, Durolane, for intra-articular injection, per dose

C9466 Injection, benralizumab, 1 mg

C9467 Injection, rituximab and hyaluronidase, 10 mg

C9468 Injection, factor IX (antihemophilic factor, recombinant), glycopegylated, Rebinyn, 1 IU

C9469 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg


New HCPCS Drug Q-Codes effective April 1, 2018:

CMS created 2 new drug Q-codes to replace Q5102 effective April 1, 2018 (see additional information below). These new codes appear with our March 1, 2018 update to give you time to update your system(s).

Q5103 Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg

Q5104 Injection, infliximab-abda, biosimilar, (Renflexis), 10 mg


Code Description Change HCPCS Q-Code effective April 1, 2018

CMS has revised the code description for Q5101 to include the trade name of the product effective for April 1, 2018. This revision is due to the new Medicare Part B policy changes for biosimilar biological products (see additional information below).

New Q5101     Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 microgram

Current:Injection, filgrastim, (G-CSF), biosimilar, 1 microgram

Please note: You will be able to view both the new and old code descriptions in our April 1, 2018 update.


Deleted HCPCS Q-Code effective March 31, 2018

Effective for claims with dates of service on or after April 1, 2018 HCPCS Code Q5102 (which describes both currently available versions of infliximab biosimilars) will be replaced with two new HCPCS codes, Q5103 and Q5104 (see above for details).

Q5102 Injection, infliximab, biosimilar, 10 mg will be deleted, effective March 31, 2018.




Part B Biosimilar Biological Product Payment and Required Modifiers Update for Dates of Service on or after April 1, 2018:

CMS has updated the Medicare Part B policy for biosimilar biological products effective for dates of service on or after April 1, 2018.

Effective January 1, 2018, newly approved biosimilar biological products with a common reference product name will no longer be billable under the same HCPCS code.

Effective for claims with dates of service on or after April 1, 2018, HCPCS code Q5102 (see code description above) will be replaced with two new HCPCS Q-codes, Q5103 and Q5104 (see code descriptions above). Also, beginning on April 1, 2018 the use of modifiers that describe the manufacturer of a biosimilar (eg., ZA, ZB and ZC) are no longer required on biosimilar HCPCS codes for Medicare claims.

Please note: The biosimilar modifier requirement for HCPCS code Q5102 remains in effect until the code is deleted effective March 31, 2018.

Please click on the link for full details regarding the new policy



Implementation of the Transitional Drug Add-On Payment Adjustment (TDAPA) – PARSABIV (J0606) and Sensipar (J0604):

CMS released information for End-Stage Renal Disease (ESRD) facilities submitting claims to Medicare Administrative Contractors (MACs) for certain ESRD drugs provided to Medicare beneficiaries.

This policy directs the MACS to implement the Transitional Drug Add-On Payment Adjustment (TDAPA). This information is to provide you with more descriptive examples for Parsabiv (J0606) and Sensipar (J0604).

The payment limits for ESRD PPS TDAPA Drugs and Biologicals effective January 1, 2018 through March 31, 2018 are noted below. Please note:  Brand names are noted in parenthesis and italics.

        • J0604 Cinacalcet, oral, 1 mg, (for ESRD on dialysis) (Sensipar), Payment limit $0.909 per 1 mg
        • J0606 Injection, etelcalcetide, 0.1 mg (Parsabiv), Payment limit $3.466 per 0.1 mg

Please see the following links for further details regarding this policy:




This month, during our review of the 2978 Reimbursement HCPCS/CPT® Codes in our system, we identified 58 Drug Codes that required a recalculation of their AWP Code Price. Log into www.reimbursementcodes.com to view the pricing updates for these codes.



J0698 J9025
A4253 J0840 J9045
A4259 J1439 J9171
A6010 J1627 J9206
A6248 J1630 J9263
A9505 J1800 Q2009
A9520 J1817 Q3028
A9556 J1953 Q9957
A9558 J2501 Q9963
B4158 J2840 Q9967
C9275 J3000 S0078
J0153 J3030 S0170
J0290 J3260 S0172
J0500 J7030 S0178
J0572 J7181 S0194
J0573 J7182 S1090
J0574 J7511 S5553
J0575 J7605 S5570
J0592 J8540
J0637 J9000


 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 four 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 four drugs that required updating.



ERLEADA™ (apalutamide) tablets, for oral use – by Janssen Biotech

GIAPREZA™ (angiotensin II) Injection for Intravenous Infusionby La Jolla Pharmaceutical

 LUTATHERA® (lutetium Lu 177 dotatate) injection, for intravenous useby Advanced Accelerator Applications USA, Inc.

SINUVA™ (mometasone furoate) sinus implantby Intersect ENT


 IMFINZI® (durvalumab) injection, for intravenous useby AstraZeneca

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

 SIMPONI® (golimumab) injection, for subcutaneous useby Janssen Biotech

        • Warnings and Precautions

 ZYDELIG® (idelalisib) tablets, for oral useby Gilead Sciences

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

 ZYTIGA® (abiraterone acetate) tablets for oral useby Janssen Biotech

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



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.

2018 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 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.