Specialty Drug Reimbursement – Newsletter – May 2019 – Volume 19, Issue 5


CMS News

  • New, Revised, and Deleted HCPCS® Effective July 1, 2019 Upcoming in the June Update

Drug Reimbursement Code Price Updates


  • New Clinical and Billing Information

Software Updates

  • Data Enhancements Coming Soon


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 71 AWP Drug Code Price changes this month, 22 (31%) 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:

  • J3465 Injection, voriconazole, 10 mg 53%
  • J0594 Injection, busulfan, 1 mg 50%
  • J0697 Injection, sterile cefuroxime sodium, per 750 mg 29%

Price Increases:

  • J7320 Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1 mg (Code re-used by CMS effective 1/1/17) (GenVisc 850 dose is 25 mg/2.5 mL) (Note: Total dose regimen = 3 – 5 injections) 135%
  • Q4184 Cellesta, per square centimeter 73%
  • S0175 Flutamide, oral, 125 mg  69%

CMS News:

CMS (Centers for Medicare & Medicaid Services) have released a set of new, revised, and deleted HCPCS® codes effective July 1, 2019.  The new codes will be crosswalked appropriately in our June publication for customers to update their systems ahead of time and prepare for the changes.  These codes will become billable on July 1st.  The following is a list of codes which will be available and/or revised:

New HCPCS® Codes:

J9030-BCG live intravesical instillation, 1 mg

J9036- Injection, bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mg

J1444-Injection, ferric pyrophosphate citrate powder, 0.1 mg of iron

J7208-Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.

J7677-Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through DME, 1 microgram

J9356-Injection, trastuzumab, 10 mg and Hyaluronidase-oysk

Q5112-Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg

Q5113-Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg

Q5114-Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg

Q5115-Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg

Revised HCPCS® Codes:


                Old Description: Injection, trastuzumab, 10 mg

                New Description: Injection, trastuzumab, excludes biosimilar, 10 mg

Deleted HCPCS® Codes:

J9031-bCG (intravesical), per installation


This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 71 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.

90621 B4154 J0775 J2060 J7322 J9357
90670 B4158 J0780 J2185 J7326 J9371
A4213 B4159 J1120 J2590 J7614 Q0138
A4253 B5000 J1290 J2675 J8565 Q0139
A4331 B5200 J1322 J2786 J8655 Q2043
A4351 C9290 J1439 J3145 J9025 Q4101
A4357 C9293 J1458 J3243 J9032 Q4184
A9155 J0185 J1559 J3285 J9057 S0032
A9543 J0290 J1726 J3465 J9206 S0175
A9558 J0401 J1744 J7030 J9225 S0189
B4103 J0594 J1817 J7050 J9226 S5571
B4153 J0697 J2020 J7320 J9307


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 three new drug which needed to be added to our database. Our review of existing drugs in our database with clinical and billing information already assigned identified three drugs that required updating.


BALVERSA™ (erdafitinib) tablets, for oral use-by Janssen Products, LP

HERCEPTIN HYLECTA™ (trastuzumab and hyaluronidase-oysk) injection, for subcutaneous useby Genentech, Inc.

EVENITY™ (romosozumab-aqqg) injection, for subcutaneous use- by Amgen Inc.


IBRANCE® (palbociclib) capsules, for oral use-by Pfizer Labs

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

PEGASYS® (peginterferon alfa-2a) Injection for subcutaneous Use- by Hoffman-La Roche Inc.

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

ICLUSIG® (ponatinib) tablets, for oral use-by Takeda Pharmaceuticals Company Limited

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


Quick Price Change and Crosswalk Addition Reference

Expect to see new enhancements to your data coming soon!  This will include more NDCs cross-walked, updated pricing methodology, and the addition of CMS’ Medically Unlikely Edit (MUE) values.

For more detailed information regarding the update Click Here.

Last month’s Newsletter


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