Specialty Drug Reimbursement – Newsletter – May 2018 – Volume 18, Issue 05


Code Updates:

        • NDC Crosswalk update for HCPCS Code(s) J7050, J7040, and J7030
        • NEW HCPCS Q-Codes effective July 1, 2018

 Drug Reimbursement Code Price Updates


        • New Clinical and Billing 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 68 AWP Drug Code Price changes this month, 16 (24%) 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:

 J3475   Injection, magnesium sulfate, per 500 mg

        • Decrease of 40% due to 2 new generic NDCs entering market shifting median down

 J2469   Injection, palonosetron HCl, 25 mcg

        • Decrease of 37% due to 8 new generic NDCs entering market

 J2710  Injection, neostigmine methylsulfate, up to 0.5 mg

        • Decrease of 29% due to decrease for lowest brand NDC


 Price Increases:

 J0280  Injection, aminophyllin, up to 250mg

        • Increase of 240% due to inactivation of 2 generic NDCs shifting median up

J2765   Injection, metoclopramide HCl, up to 10 mg

        • Increase of 140% due to increase for 2 generic NDCs shifting median up

Q2009   Injection, fosphenytoin, 50 mg phenytoin equivalent

        • Increase of 21% due to increase for 4 generic NDCs shifting median up

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

CMS has created 4 new drug Q-codes that are payable by Medicare effective for claims with dates of service on or after July 1, 2018. Please note: Brand names are noted in parenthesis and italic if not already noted in the code description.


  • Q9991 Injection, buprenorphine extended-release (Sublocade), less than or equal to 100 mg
  • Q9992 Injection, buprenorphine extended-release (Sublocade), greater than 100 mg
  • Q9993   Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg (Zilretta)
  • Q9995 Injection, emicizumab-kxwh, 0.5 mg (Hemlibra)


CMS has also created 1 new Q-code effective July 1, 2018 that is not payable by Medicare.

  • Q9994 In-line cartridge containing digestive enzyme(s) for enteral feeding, each (Relizorb)


These new codes will appear in our June 1, 2018 update ahead of their effective date to allow our clients to update their system(s).


This month, during our review of the 2978 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.


A6196 J0894 J7324 J9307
A9507 J0895 J7325 J9357
A9604 J1162 J7327 J9371
A9606 J1453 J8530 J9395
B4149 J1568 J9023 Q0138
B4153 J1631 J9032 Q0139
B4155 J1956 J9034 Q0162
B4157 J2357 J9043 Q2009
C9293 J2469 J9060 S0078
C9492 J2710 J9175 S0119
E0607 J2765 J9179 S0191
J0131 J2783 J9209 S4991
J0280 J2786 J9225 S5553
J0476 J3145 J9226 S5570
J0490 J3285 J9228
J0594 J3396 J9264
J0744 J3475 J9299
J0775 J7183 J9305



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 no 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.



AFINITOR DISPERZ® (everolimus tablets for oral suspension) – by Novartis (NOC Codes: C9399, J8999)

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


PRAXBIND® (idarucizumab), for intravenous useby Boehringer Ingelheim Pharmaceuticals, Inc.  (NOC Codes: C9399, J3590)

        • Indications & Usage, Dosage & Administration


RUBRACA® (rucaparib) tablets, for oral use – by Clovis Oncology (NOC Codes: C9399, J8999)

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


TAGRISSO® (osimertinib) tablets, for oral useby AstraZeneca (NOC Codes: C9399, J8999)

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


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