Specialty Drug Reimbursement – Newsletter – November 2018 – Volume 18, Issue 11


Code Updates:

  • Update -J-Code 1599 Addition of 12 active NDCs
  • Update- Removal of minimum and maximum dosing for J1325 and J3285
  • Update- Revision of maximum dose for J2278

 CMS News:

  • Medicare Influenza Vaccine Pricing 2018-2019 Season
  • NEW Influenza CPT® Code 90689 Effective January 1, 2019
  • NEW HCPCS® Codes and Changed Code Descriptions Upcoming in the December Update

 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 86 AWP Drug Code Price changes this month, 40 (47%) 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:

  • J0641 Injection, levoleucovorin calcium, 0.5 mg: Decrease of 84%
  • A4404  Ostomy ring, each (Code Price is based on median pricing methodology): Decrease of 54%
  • S0117  Tretinoin, topical, 5 grams: Decrease of 43%
  • J9171 Injection, docetaxel, 1 mg: Decrease of 43%

 Price Increases:

  • A4369  Ostomy skin barrier, liquid (spray, brush, etc.), per oz (Code Price is based on median pricing methodology): Increase of 78%
  • J1790 Injection, droperidol, up to 5 mg: Increase of 58%
  • A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz. (Code Price is based on median pricing methodology): Increase of 51%

Update – J-Code 1599 Addition of 12 Active NDCs

Following the approval of a new intravenous immune globulin product (Panzyga) 12 NDCs were cross-walked to J1599. Previously this code had no active NDCs cross-walked.

Update – Removal of Min/Max Dosing for J1325 and J3285

Following a clinical committee review of J1325 and J3285 it was decided to remove FDA and compendia minimum and maximum dosing due to high patient variability and constant titration of the medications during treatment. For information on RJ Min/Max Values please log into ReimbursementCodes.com

J1325  Injection, epoprostenol, 0.5 mg

J3285  Injection, treprostinil, 1 mg

Update: Revision of Max Dose for J2278

Following a clinical committee review of J2278 it was decided the pediatric and adult, FDA and compendia maximum doses were increased, to accommodate the maximum capacity of the ambulatory pump used for administration of the medication. For information on RJ Min/Max Values please log into ReimbursementCodes.com

J2278  Injection, ziconotide, 1 microgram

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.

NEW HCPCS® Codes and Changed Code Descriptions Upcoming in the December Update

New HCPCS® Codes will be cross-walked to NOC codes in our December publication for customers to update their systems.  These codes will become billable January 1st. CMS has updated code descriptions as well which will also be published during the December update, so customers can prepare for the changes. A supplemental newsletter will be released during November describing these new codes and description changes.


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.

86580 A4373 A4416 A5131 C9463 J2680 J9171 S0117
A4216 A4394 A4419 A6237 C9493 J3145 J9201 S4991
A4245 A4397 A4425 A6238 J0364 J3489 J9225  
A4253 A4399 A4426 A6248 J0641 J7030 J9226  
A4349 A4404 A4433 A7003 J0775 J7050 J9307  
A4353 A4405 A4455 A7005 J0894 J7060 J9357  
A4357 A4406 A5055 A9543 J0895 J7070 J9371  
A4361 A4409 A5056 B4104 J1162 J7324 Q0138  
A4363 A4410 A5061 B4152 J1599 J7327 Q0139  
A4367 A4413 A5071 B4155 J1631 J7345 Q2043  
A4368 A4414 A5120 B4162 J1790 J9032 Q4123  
A4369 A4415 A5122 C9285 J2469 J9100 Q4141


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


  • XERAVA™ (eravacycline dihydrochloride) injection, for intravenous use – by Tetraphase Pharmaceuticals, Inc.
  • COPIKTRA™ (duvelisib), capsules, for oral use – by Verastem, Inc.
  • VIZIMPRO® (dacomitinib) tablets, for oral use by Pfizer Inc.
  • EMGALITY™ (galcanezumab-gnlm) injection, for subcutaneous use by Lilly
  • LUMOXITI™ (moxetumomab pasudotox-tdfk), injection, for intravenous use- by AstraZeneca
  • LIBTAYO® (cemiplimab-rwlc) injection, for intravenous use-by Regeneron Pharmaceuticals, Inc
  • CLOROTEKAL® (chloroprocaine hydrochloride) injection, for intrathecal use-by B. Braun Medical Inc.
  • TALZENNA™ (talazoparib) capsules, for oral use-by Pfizer Inc


  • DUPIXENT® (dupilumab) injection, for subcutaneous use by Regeneron Pharmaceuticals

Indications & Usage, Dosage & Administration, ICD-10-CM codes

  • CAPRELSA® (vandetanib) tablets, for oral use by AstraZeneca Pharmaceuticals LP

Indications & Usage and Dosage & Administration

  • ZYDELIG® (idelalisib) tablets, for oral use- by Gilead Sciences, Inc.

Dosage & Administration, ICD-10-CM codes

Previous Newsletter:

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

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