Specialty Drug Reimbursement – Newsletter – April 2018 – Volume 18, Issue 04


Code Updates:

CMS News:

Drug Reimbursement Code Price 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 60 AWP Drug Code Price changes this month, 20 (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:

 J0594   Injection, busulfan, 1 mg

  • Decrease of 46% due to decrease for 2 generic NDCs

J1644   Injection, heparin sodium, per 1,000 units

  • Decrease of 44% due to 12 new generic NDCs entering market

J0698  Cefotaxime sodium, per gram

  • Decrease of 39% due to inactivation of 2 generic NDCs


Price Increases:

A9507  Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries (Code Price is per 1 vial = 5 millicuries)

  • Increase of 100% due to increase by manufacturer

A9540   Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries (Code Price is per 1 vial)

  • Increase of 50% from due to 1 new NDC added to crosswalk and inactivation of lowest brand NDC

Q9968   Injection, non-radioactive, non-contrast, visualization adjunct (e.g., Methylene Blue, Isosulfan Blue), 1 mg

  • Increase of 18% due to increase for 4 generic NDCs


Reminder – 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 codes appear with our April 1, 2018 update. Please note:  Brand names, if applicable, are noted in parenthesis and italics if not already noted in the code description.

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


Reminder – 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 in our April 1, 2018 update.

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

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


Reminder – 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

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

Please note: You will be able to view both the new and previous code descriptions in our April 1, 2018 update. The old code description appears with a strikethrough the HCPCS code.


Reminder – 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 was deleted effective March 31, 2018.




Reminder – 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) was 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 was deleted effective March 31, 2018.

Please click on the link for full details regarding the new policy https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/Part-B-Biosimilar-Biological-Product-Payment.html


January 2018 Quarterly ASP (Average Sales Price) Pricing File Revised:

CMS has made revisions to the January 2018 Quarterly ASP pricing file for certain HCPCS codes. The revised payment rates which are effective retroactively to the beginning of the quarter are provided below.

Revised ASP payment rates effective January 1, 2018 through March 31, 2018

J0636: previous rate $0.530, revised payment rate $0.605

J1626: previous rate $0.317, revised payment rate $0.298

J1956: previous rate $1.816, revised payment rate $1.353

J2360: previous rate $7.810, revised payment rate $6.533

J3489: previous rate $13.021, revised payment rate $12.854

J7510: previous rate $0.088, revised payment rate $0.079

J7612: previous rate $0.190, revised payment rate $0.177

J7682: previous rate $39.702, revised payment rate $39.574

As per CMS, “the payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufacturers. The quarter to quarter price changes are generally the result of updated data from the manufacturers of these drugs.”

Our data files and website have incorporated these changes. As a reminder, we display the most recent revised rate on the Medicare Allowable tab on the pricing screen. To view previous Medicare Allowable rates for a quarter (if revised), click on the appropriate Effective Date on the same screen. Please Note: ASP rate revisions are retroactive to the beginning of the quarter.


April 2018 NOC (Not Otherwise Classified) Pricing file – New Drug Added:

CMS released the April 1, 2018 NOC Pricing file with one new product added effective April 1, 2018.

New product added effective April 1, 2018:

  • Puraply AM – $111.670 per 1 SQ CM

To view the NOC pricing file on the website, search on a NOC (Not Otherwise Classified) code, product or NDC and click on the link “Listing of CMS ASP+6% rates for NOCs” under Additional Information on the left side of the screen.




This month, during our review of the 2990 Reimbursement HCPCS/CPT® Codes in our system, we identified 60 Drug Codes that required a recalculation of their AWP Code Price. Log in to www.DrugCodeLookUp.com to view the pricing updates for these codes.


B4157 J1602 J9047






B4160 J1644



B4162 J1741



J0207 J1800



J0594 J1885



J0630 J1940



J0698 J1953



J0706 J2250



J1245 J2274



J1322 J2760



J1458 J7304



J1561 J7320



J1572 J8540


A9540 J1580 J9031




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 five drugs that required updating



MAKENA® (hydroxyprgesterone caproate injection) for SUBCUTANEOUS Use – by AMAG Pharmaceuticals, Inc. 

TROGARZO™ (ibalizumab-uiyk) injection, for intravenous useby TheraTechnologies, Inc.



IMBRUVICA® (ibrutinib) capsules/tablets, for oral useby Pharmacyclics, Inc.

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

PURIXAN® (mercaptopurine) oral suspensionby Rare Disease Therapeutics, Inc

  • Dosage & Administration and Warnings & Precautions

TASIGNA® (nilotinib) capsules, for oral useby Novartis

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

VERZENIO™ (abemaciclib) tablets, for oral useby Lilly

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

ZINBRYTA™ (daclizumab) injection, for subcutaneous useby Biogen and Abbvie

  • Voluntary withdrawal from U.S. Market notice




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