Specialty Drug Reimbursement – Newsletter – August 2018 – Volume 18, Issue 08


Code Updates:

  • Large Price Changes
  • COMING SOON – New Q-Code Effective October 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 72 AWP Drug Code Price changes this month, 16 (22%) were price decreases. The table in the Drug Reimbursement Code Price Updates section includes all AWP drug Code Price changes for this month. Please note:  These numbers represent AWP Code Price changes only. See below for examples of codes with significant price changes this month.


Price Decreases:

 J2795   Injection, ropivacaine hydrochloride, 1 mg:

  • Decrease of 55% to 2 new generic NDCs entering market shifting median down

J7321   Hyaluronan or derivative, Hyalgan or Supartz or Visco-3, for intra-articular injection, per dose:

  • Decrease of 34% due to decrease for lowest brand NDC

J9340   Injection, thiotepa, 15 mg:

  • Decrease of 11% due to 1 new generic NDC entering market shifting median down

Price Increases:

 J1245   Injection, dipyridamole, per 10 mg:

  • Increase of 303% due to increase for 2 generic NDCs shifting median up

J2720   Injection, protamine sulfate, per 10 mg:

  • Increase of 17% due to increase for 4 generic NDCs shifting median up

J3121   Injection, testosterone enanthate, 1 mg:

  • Increase of 13% due to increase for 1 generic NDC shifting median up

COMING SOON – New HCPCS Drug Q-Code effective October 1, 2018:

CMS (Centers for Medicare & Medicaid Services) has created 1 new drug Q-code effective for Medicare claims with dates of service on or after October 1, 2018.

Q5108 Injection, pegfilgrastim-jmdb, biosimilar, (Fulphila), 0.5 mg

Please note: Q5108 will be added to the website and files with our September 1, 2018 update to give you time to update your internal systems.

Effective with our August 1, 2018 update Fulphila (pegfilgrastim-jmdb) injection, a biosimilar to Neulasta® can be billed using NOC Codes C9399 Unclassified drugs or biologicals for Hospital Outpatient billing or J3590 Unclassified biologics for physician billing until Q5108 becomes effective October 1, 2018.


This month, during our review of the 2986 Reimbursement HCPCS/CPT® Codes in our system, we identified 72 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.

90653 B4158 J0289 J1575 J2278 J3121 J9035 J9355 S0078
90656 C9016 J0401 J1626 J2407 J3260 J9042 Q0138 S0109
90658 C9257 J1245 J1729 J2469 J3262 J9301 Q0139 S0119
90662 C9467 J1250 J1942 J2501 J7321 J9306 Q0162 S0169
90682 E0607 J1335 J2020 J2720 J7503 J9307 Q2009 S0189
90685 J0202 J1439 J2060 J2785 J8655 J9310 Q2035 S4991
A4802 J0256 J1555 J2185 J2795 J9022 J9340 S0017 S5553
A9543 J0257 J1559 J2265 J3095 J9032 J9354 S0020 S5566



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 six 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 seven drugs that required updating.


ARISTADA INITIO™ (aripiprazole lauroxil) extended-release injectable suspension, for intramuscular use by Alkermes, Inc.  (NOC Codes: C9399, J3490)

BRAFTOVI™ (encorafenib) capsules, for oral use – by Array Biopharma (NOC Codes: C9399, J8999)

FULPHILA™ (pegfilgrastim-jmdb) injection, for subcutaneous use (biosimilar to Neulasta®)by Mylan Institutional (NOC Codes: C9399, J3590) (Q5108 effective 10/1/18)

MACRILEN® (macimorelin) for oral solutionby Strongbridge Biopharma (NOC Codes: C9399, J8499)

MEKTOVI® (binimetinib) tablets, for oral useby Array Biopharma (NOC Codes: C9399, J8999)

ZEMDRI™ (plazomicin) injection, for intravenous use – by Achaogen, Inc. (NOC Codes: C9399, J3490)


ALECENSA® (alectinib) capsules, for oral use by Genentech (NOC Codes: C9399, J8999)

  • Dosage & Administration

BORTEZOMIB for injection, for intravenous useby Fresenius Kabi USA (NOC Codes: C9399, J8999)

  • Dosage & Administration

KISQALI® (ribociclib) tablets, for oral useby Novartis (NOC Codes: C9399, J8999)

  • Indications & Usage and Dosage & Administration

NERLYNX® (neratinib) tablets, for oral useby Puma Technology (NOC Codes: C9399, J8999)

  • Dosage & Administration

PROMACTA® (eltrombopag) tablets, for oral useby Novartis (NOC Codes: J8499)

  • Dosage & Administration

VENCLEXTA® (venetoclax tablets) for oral useby Abbvie (NOC Codes: C9399, J8999)

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

XTANDI® (enzalutamide) capsules, for oral useby Astlellas (NOC Codes: C9399, J8999)

  • Indications & Usage and Dosage & Administration


Previous Newsletter:

Specialty Drug Reimbursement – Newsletter – July 2018 – Volume 18, Issue 07

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