Specialty Drug Reimbursement – Newsletter – January 2019 – Volume 19, Issue 1


Code Updates:

  • Large Price Changes
  • New HCPCS® Codes and Changed Code Descriptions are Now Effective
  • Code Strength Description Changes for New HCPCS® Codes

CMS News:

  • CMS Final Ruling on Medicare Physician Schedule Now Effective
  • Quarterly ASP (Average Sales Price) Pricing File Released
  • Hospital OPPS (Outpatient Prospective Payment System) Update

Drug Reimbursement Code Price Updates:

  • 45 drug code price changes this month


  • New Clinical and Billing Information


  • Innovative New Widgets
  • New NDC Lookup Feature


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 45 AWP Drug Code Price changes this month, 11 (23%) 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:

  • J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg (Code reinstated effective 4/1/2008): Decrease of 32%
  • J1450 Injection, fluconazole, 200 mg: Decrease of 17%
  • J9171 Injection, docetaxel, 1 mg: Decrease of 16%

 Price Increases:

  • J9070 Cyclophosphamide, 100 mg: Increase of 12%
  • J3250 Injection, trimethobenzamide HCl, up to 200 mg: Increase of 10%
  • J0282 Injection, amiodarone hydrochloride, 30 mg: Increase of 8%

REMINDER – New HCPCS Codes are Now Effective

CMS (Centers for Medicare & Medicaid Services) released their annual Alpha-Numeric HCPCS File for 2019.  All new codes have been added to ReimbursementCodes.com and are now effective. These drug codes became effective for Medicare billing for dates of service on and after January 1, 2019.  HCPCS drug code description changes, and deleted HCPCS drug codes are also now effective and can be reviewed on ReimbursementCodes.com.

For a complete list regarding these HCPCS® Code updates please refer to our November and December newsletters.

Code Strength Description Changes for New HCPCS® Codes

During the January 1, 2019 update, four drugs that were placed into permanent codes had changes to the strengths specified in the code descriptions which may therefore change the way these drugs are billed.  The following were the new affected codes:

  • J2062-Adasuve®
  • J7318-Durolane®
  • J9312-Rituxan®
  • Q2042-Kymriah™

CMS News:

CMS Final Ruling on Medicare Physician Schedule Now Effective:

As mentioned in our previous newsletters CMS has issued a final ruling on November 1, 2018 regarding WAC-based payments for Part B Drugs which will be effective on and after January 1, 2019.  When ASP is unavailable for a drug, it will now be subject to a 3 percent add-on in place of the 6 percent add-on.  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’.

Quarterly ASP (Average Sales Price) File Released:

Another quarter has passed, and this means CMS has released the 2019 ASP pricing and revisions file. These rates are effective January 1, 2019 through March 31, 2019. This new ASP pricing file is incorporated in our own data and website. To view the most recent revised rates simply click on the Medicare Allowable tab on the pricing screen.

As per CMS, “the payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufacturers. The quarter to quarter price changes are generally the result of updated data from the manufacturers of these drugs.”

This file also includes any revisions made to previous quarter pricing. However, no revisions were made this quarter.  If there were revisions made these would be viewed by clicking on the appropriate Effective Date on the pricing tab screen. Please Note: ASP rate revisions are retroactive to the beginning of the quarter.


This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 45 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 90713 B4161 J1670 J7614
90281 90714 B4185 J1953 J9017
90283 90734 J0282 J2469 J9025
90376 A4215 J0290 J2790 J9070
90384 A9155 J1450 J3243 J9171
90389 A9588 J1460 J3250 Q4102
90691 B4152 J1560 J3489 Q4124
90698 B4154 J1572 J7175 S0157
90702 B4155 J1627 J7503 S8490


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 four 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 four drugs that required updating.



VITRAKVI® (larotrectinib) capsules and oral solution, for oral useby Loxo Oncology, Inc.

DAURISMO™ (glasdegib) tablets, for oral use by Pfizer Labs

KHAPZORY™ (levoleucovorin) for injection, for intravenous useby Spectrum Pharmaceuticals

NUZYRA™ (omadacycline) for injection, intravenous useby Paratek Pharmaceuticals, Inc.



VENCLEXTA® (venetoclax) tablets, for oral use– by AbbVie, Inc

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

TARCEVA® (erlotinib) tablets, for oral use- OSI Pharmaceuticals, LLC an affiliate of Astellas Pharma US, Inc

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

XALKORI® (crizotinib) capsules, for oral use – by Pfizer Labs

  • Indications & Usage, Dosage & Administration

NEXAVAR® (sorafenib) tablets, for oral use-by Bayer/Onyx Pharmaceuticals

  • Dosage & Administration


At RJ Health we are always working hard to provide our customers with best and easiest use of our data through innovative add-ons. During the past month we have created the following enhancements just to name a few:

Innovative New Widgets

Customize your ReimbursementCodes.com experience with our new widgets! These widgets can be added to the home screen and provide quick look ups.  Use the Dosing Convertor to calculate codes units to doses and doses to code units. Or use the Code Units/Dosing Reference to calculate max code units for a HCPCS® code.

These widgets can be added to the home screen by visiting the Preferences page, Layout Options and click on Quick Return View.

New NDC Lookup Feature

Having trouble looking up your NDC? We now offer 10-digit NDC search, just include the dashes.


Previous Newsletter:

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

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