Specialty Drug Reimbursement – Newsletter – October 2018 – Volume 18, Issue 10


Code Updates:

  • Update – New Q-Code Effective October 1, 2018 and July 12, 2018
  • Reminder – 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

 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 37 AWP Drug Code Price changes this month, 17 (46%) 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:

  • J1270 Injection, doxercalciferol, 1 mcg: Decrease of 65%
  • J7320  Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1mg: Decrease of 37%
  • J0894  Injection, decitabine, 1mg: Decrease of 21%

 Price Increases:

  • J0697 Injection, sterile cefuroxime sodium, per 750mg: Increase of 42%
  • J2502 Injection, pasireotide long acting, 1mg: Increase of 33%
  • A9579 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per mL: Increase of 21%

Update – New HCPCS Drug Q-Codes effective October 1, 2018 and July 12, 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

Reminder- 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. Please note:  Brand names, if applicable, are noted in parenthesis.

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

To view the CMS October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)  please see https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4123CP.pdf

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).

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 you with an update.

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 give you time to update your internal systems, if applicable.


This month, during our review of the 3011 Reimbursement HCPCS/CPT® Codes in our system, we identified 37 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.DRUG REIMBURSEMENT CODE PRICE UPDATES

90283 J0132 J0894 J1561 J3489 J7193 J9017 Q2009
90284 J0153 J1120 J1572 J7120 J7320 J9040 Q9983
A9579 J0270 J1270 J2469 J7178 J7502 J9050 S0078
B4158 J0475 J1327 J2502 J7180 J9000 Q0161 S8490
B4160 J0697 J1450 J2786 J7187  


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 eight 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


  • AJOVY™ (fremanezumab-vfrm) injection, for subcutaneous useby Teva Pharmaceuticals USA, Inc.
  • AZEDRA® (iobenguane I 131) injection, for intravenous use – by Progenics Pharmaceuticals
  • BELRAPZO™ (bendamustine hydrochloride injection), for intravenous use by Eagle Pharmaceuticals Please note: the proprietary name, BELRAPZO was recently approved by the FDA. It is currently listed as bendamustine NDC 42367-0520-25 on the website and files.
  • JIVI® [antihemophilic factor (recombinant), PEGylated-aucl] lyophilized powder for solution, for intravenous use by Bayer
  • NIVESTYM™ (filgrastim-aafi) injection, for subcutaneous or intravenous useby Pfizer NIVESTYM is a biosimilar to NEUPOGEN (filgrastim) by Amgen
  • OMNIPAQUE (iohexol) oral solution – by GE Healthcare Inc. Please note: this oral solution is supplied as 9mg and 12 mg of iodine per mL
  • TAKHZYRO™ (lanaadelumab-flyo) injection, for subcutaneous use – by Shire US, Inc
  • TRIVISC™ (sodium hyaluronate) for intra-articular injection – by OrthogenRx, Inc


  • ACTEMRA® (tocilizumab) injection, for intravenous or subcutaneous useby Genentech: Indications & Usage, Dosage & Administration, ICD-10-CM codes

Previous Newsletter:

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

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