Specialty Drug Reimbursement – Newsletter – December 2018 – Volume 18, Issue 12


Code Updates:

  • Large Price Changes
  • New HCPCS® Codes and Changed Code Descriptions Effective January 1, 2019

CMS News:

  • CMS Final Ruling on Medicare Physician Schedule Effective January 1, 2019

Drug Reimbursement Code Price Updates:

  • 47 Drug Codes required a recalculation of their AWP Code Price


  • 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 47 AWP Drug Code Price changes this month, 22 (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:

  • J1630 Injection, haloperidol, up to 5 mg: Decrease of 48%
  • J0735 Injection, clonidine hydrochloride, 1 mg: Decrease of 24%
  • J7120 Ringer’s lactate infusion, up to 1,000 cc: Decrease of 17%

 Price Increases:

  • J2550  Injection, promethazine HCl, up to 50 mg: Increase of 31%
  • J7194 Factor IX, complex, per IU: Increase of 27%
  • J2690 Injection, procainamide HCl, up to 1 g: Increase of 22%

Update – New HCPCS® Codes Effective Januart 1, 2019 – Now Available

CMS (Centers for Medicare & Medicaid Services) has released the annual Alpha-Numeric HCPCS File for 2019.  All new codes have been added to ReimbursementCodes.com.  Drug Codes become effective for Medicare billing for dates of service on or after January 1, 2019.  Please refer to the Supplemental Newsletter for November 2018 for a full list of new HCPCS® codes, HCPCS® drug code description changes, and deleted HCPCS® drug codes effective for January 1, 2019.

CMS News:

CMS Final Ruling on Medicare Physician Schedule Effective January 1, 2019:

CMS Final Ruling on Medicare Physician Schedule Effective January 1, 2019:

CMS issued a final ruling on November 1, 2018 regarding WAC-based payments for Part B Drugs which will be effective on or after January 1, 2019.  When ASP is unavailable for a drug, it will be subject to a 3 percent add-on in place of the 6 percent add-on that is currently being used.  For additional information, please visit: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year

As a reminder, you can set WAC+3% as a default discount rate on the reimbursementcodes.com website by visiting your Preferences section then ‘Discounts/Additions’.



This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 47 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.

90632 A9155 J0780 J3475 Q0166
90651 B4104 J1557 J7120 Q9958
90707 B4154 J1630 J7194 Q9994
90710 B4155 J1956 J9025 S0091
90716 B4161 J2360 J9050 S0178
90732 E0607 J2469 J9070 S0194
A4216 E2100 J2550 J9185 S8490
A4217 J0637 J2690 J9266
A4253 J0690 J2820 J9271
A4256 J0735 J3030 J9340


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 five 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 drugs that required updating.



LORBRENA® (lorlatinib) tablets, for oral use-by Pfizer

REVCOVI™ (elapegademase-lvlr) injection, for intramuscular use-by Leadiant Biosciences Inc.

TEGSEDI™ (inotersen) injection, for subcutaneous use- by Ionis Pharmaceuticals, Inc.

ANAVIP® Crotalidae Immune F(ab’)2 (Equine) Lyophilized Powder for Solution for Injection, Intravenous Use Only- by Rare Disease Therapeutics, Inc.

XOFLUZA™ (baloxavir marboxil) tablets, for oral use- by Shionogi & Co., Ltd.



PROMACTA® (eltrombopag) tablets, for oral use, for oral suspension- by Novartis

  • Indications & Usage and Dosage & Administration

Previous Newsletter:

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

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