Specialty Drug Reimbursement – Newsletter – September 2018 – Volume 18, Issue 09


Code Updates:

  • Large Price Changes
  • New Q-Codes Effective October 1, 2018
  • New C-Codes for Hospital OPPS use Effective October 1, 2018

CMS News:

  • Medicare Influenza Vaccine Pricing 2018-2019 Season
  • NEW Influenza CPT® Code 90689 Effective January 1, 2019
  • Medicare Coverage Indicator Change for Q9994

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 48 AWP Drug Code Price changes this month, 15 (31%) were price decreases. The table in the Drug Reimbursement Code Price Updates section within our subscription website includes all AWP drug Code Price changes for this month. Below are examples of codes with significant price changes this month. Please log into our subscription site for details on specific prices and the rational for the change.


Price Decreases:

  • J2710 Injection, neostigmine methylsulfate, up to 0.5 mg: Decrease of 60%
  • J0287 Injection, amphotericin B lipid complex, 10 mg:  Decrease of 49%
  • J2370 Injection, phenylephrine HCl, up to 1 mL: Decrease of 20%

 Price Increases:

  • Q4117 Hyalomatrix, per square centimeter:  Increase of 49%
  • J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg: Increase of 47%
  • J9000 Injection, doxorubicin hydrochloride, 10 mg: Increase of 12%


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

CMS (Centers for Medicare & Medicaid Services) has created 2 new drug Q-codes effective October 1, 2018. However, CMS has indicated that Q5108 will be payable by Medicare retro-active to July 12, 2018.

  • Q5108 Injection, pegfilgrastim-jmdb, biosimilar, (Fulphila), 0.5 mg
  • Q5110 Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 microgram
NDC NDC Strength NDC package WAC effective 9/24/18
00069-0291-01 300 mcg/0.5 mL 1 PF* pre-filled syringe For specific pricing please log into ReimbursementCodes.com
00069-0291-10 300 mcg/0.5 mL 10 PF* pre-filled syringes
00069-0292-01 480 mcg/0.8 mL 1 PF* pre-filled syringe
00069-0292-10 480 mcg/0.8 mL 10 PF* pre-filled syringes

*PF (preservative-free)


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

CMS has created 2 new HCPCS drug C-codes effective October 1, 2018 for Medicare’s Hospital OPPS (Outpatient Prospective Payment System) billing. These new codes appear with our September 1, 2018 release. Please note:  Brand names, if applicable, are noted in parenthesis and italics.

  • C9033 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg (Akynzeo)
  • C9034 Injection, dexamethasone 9%, intraocular, 1 mcg (Dexycu)

CMS News:

Medicare Influenza Vaccine Pricing for 2018-2019 Season:

CMS has released the Medicare Part B payment allowance limits for the seasonal influenza vaccines for the 2018-2019 season. These payment limits are effective for Dates of Service 8/1/18 – 7/31/19. The Medicare Part B payment limits for seasonal influenza are 95% of the Average Wholesale Price (AWP).

These rates will be available on the website and files with our October 1, 2018 release. Since these rates became effective 8/1/18 we are providing them ahead of the October 1st release.

HCPCS/CPT® Code Payment Limit
90653 For specific pricing please log into ReimbursementCodes.com


According to the CMS website, payment limits for certain codes are pending payment allowances. We will monitor CMS for any updates to these pending rates and provide updates.

NEW Influenza CPT® Code 90689 Effective January 1, 2019:

The AMA (American Medical Association) has created one new influenza virus vaccine code effective on or after January 1, 2019.

Effective for claims processed with Dates of Service (DOS) on or after January 1, 2019, 90689 Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use will be payable by Medicare. Please note: The product for this code is still pending FDA approval.

CMS has released the following information regarding this code. ”The new influenza virus vaccine code 90689 is not retroactive to August 1, 2018. No claims should be accepted for influenza virus vaccine code 90689 between the DOS August 1, 2018 and December 31, 2018. If claims are received in January 2019 with code 90689 for DOS between August 1, 2018 and December 31, 2018, contractors should follow their normal course of action for codes billed prior to their effective date.”

To view the CMS transmittal regarding this and January 2019 Influenza Virus Vaccine information please see https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4127CP.pdf

Please note: 90689 will be available in our data with our December 1, 2018 release to provide customers with the time needed to update systems, if applicable.

Medicare Coverage Indicator Change for Q9994:

Effective for dates of service on or after July 13, 2018, the Medicare coverage indicator changed for code Q9994 In-line cartridge containing digestive enzyme(s) for enteral feeding, each from “I” that means “not payable by Medicare” to “D” which means “special coverage instructions apply”. This change is effective for dates of service on or after July 13, 2018. This will be updated in our files for our October 1, 2018 update.


This month, during our review of the 2990 Reimbursement HCPCS/CPT® Codes in our system, we identified 48 Drug Codes that required a recalculation of their AWP Code Price. Log into www.ReimbursementCodes.com to view the pricing updates for these codes.


B4160 J0290 J1571 J2405 J7120 J9267 Q4133


B5100 J0795 J1573 J2690 J7192 J9315 S0032


C9024 J0840 J1627 J2710 J7614 J9330 S0078
A9600 C9488 J1335 J1726 J2792 J9000 Q2009


B4150 E2100 J1459 J1741 J7042 J9179 Q4117


B4158 J0287 J1460 J2370 J7050 J9207 Q4132




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 one drug that required updating. For specific coding assignments please log into ReimbursementCodes.com


  • GALAFOLD™ (migalastat) capsules, for oral useby Amicus Therapeutics
  • ILUMYA™ (tildrakizumab-asmn) injection, for subcutaneous use by Sun Pharmaceuticals
  • MULPLETA® (lusutrombopag) tablets for oral use by Shionogi
  • ONPATTRO™ (patisiran) lipid complex injection, for intravenous use by Alnylam Pharmaceuticals
  • PERSERIS™ (risperidone) for extended-release injectable suspension, for subcutaneous useby Indivior
  • POTELIGEO® (mogamulizumab-kpkc) injection, for intravenous use – by Kyowa Kirin, Inc
  • TIBSOVO® (ivosidenib) tablets, for oral use – by Agios Pharmaceuticals


  • LENVIMA® (lenvatinib) capsules, for oral useby Eisai: Indications & Usage, Dosage & Administration, ICD-10-CM codes

Previous Newsletter:

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

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