Specialty Drug Reimbursement – Newsletter – June 2018 – Volume 18, Issue 06


Code Updates:


Drug Reimbursement Code Price Updates


New Webinar:

Shedding Light on Medically Covered Specialty Drug Pricing Methods
NDC UOM Webinar

Let’s discuss Specialty Drug Pricing Methods…

Why do they exist? How do they differ? When are they used? How do they impact your reimbursement?



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 28 AWP Drug Code Price changes this month, 10 (36%) 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:

J9209   Injection, mesna, 200 mg

  • Decrease of 32% due to 2 new generic NDCs entering market shifting median down

J2590   Injection, oxytocin, up to 10 units

  • Decrease of 17% due to re-activation of lowest brand NDC

J0743  Injection, cilastatin sodium; imipenem, per 250 mg

  • Decrease of 12% due to inactivation of 2 generic NDCs shifting median down

Price Increases:

J3475  Injection, magnesium sulfate, per 500 mg

  • Increase of 65% due to inactivation of 2 generic NDCs shifting median up

B4149   Enteral formula, manufactured blenderized natural foods with intact nutrients includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 cals = 1 unit

  • Increase of 54% due to 9 new NDCs entering market shifting median up

J3010   Injection, fentanyl citrate, 0.1 mg

  • Increase of 13% due to increase for 5 generic NDCs shifting median up


Reminder- 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 July1, 2018 that is not payable by Medicare.

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

These new codes appear in our June 1, 2018 update ahead of their effective date so you have time to update your system(s).

For the CMS Transmittal regarding these new HCPCS codes please see https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4048CP.pdf


April 2018 NOC (Not Otherwise Classified) Pricing file Updated:

On May 2, 2018 CMS updated the April 1, 2018 NOC Pricing file adding an additional new product and information regarding payment limits to include the clotting factor furnishing fee.

New product added May 2, 2018 effective on or after April 1, 2018 through June 30, 2018:

  • emicizumab (Hemlibra)


The Blood Clotting Factor Furnishing Fee for 2018 is $0.215 per unit. Please note for Hemlibra the fee is per 0.5 mg (see above). For more information on The Blood Clotting Factor Furnishing Fee see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/ClotFactorFurnishFee.html


This month, during our review of the 2978 Reimbursement HCPCS/CPT® Codes in our system, we identified 28 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.


A4259 J0295 J1165 J2590 J3010 J9040


A4349 J0743 J1885 J2675 J3475 J9206
A4230 B4149 J0894 J1940 J2680 J7307


A4253 J0282 J0895 J2405 J2790 J7502



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 four drugs that required updating.


AKYNZEO® (fosnetupitant and palonsetron) for injection, for intravenous use – by Helsinn Therapeutics (NOC Codes: C9399, J3490)

ANDEXXA® (coagulation factor Xa (recombinant), inactivated-zhzo) Lyophilized Powder for Solution For Intravenous Injection – by Portola Pharmaceuticals (NOC Codes: C9399, J3590)

CRYSVITA® (burosumab-twza) injection, for subcutaneous use – by Ultragenyx Pharmaceuticals, Inc (NOC Codes: C9399, J3590)

JYNARQUE™ (tolvaptan) tablets for oral useby Otsuka America Pharmaceutical, Inc. (NOC Code: J8499)

RELIZORB® (immobilized lipase) cartridgeby Alcresta Pharmaceuticals (Q9994, effective 7/1/18)

STERITALC® (talc), powder, for intrapleural use – by Novatech S. A. (NOC Codes: C9399, J3490)

TAVALISSE™ (fostamatinib disodium hexahydrate) tablets, for oral useby Rigel Pharmaceuticals, Inc. (NOC Codes: C9399, J8499)


ACTEMRA® (tocilizumab) injection, for subcutaneous use – by Genentech (NOC Code: J3590)

  • Dosage & Administration (PJIA)

GILENYA® (fingolimod) capsules, for oral useby Novartis (NOC Code: J8499)

  • Indications & Usage, Dosage & Administration

MEKINIST® (trametinib) tablets, for oral use– by Novartis (NOC Codes: C9399, J8999)

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

TAFINLAR® (dabrafenib) capsules, for oral useby Novartis (NOC Codes: C9399, J8999)

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


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