Specialty Drug Reimbursement – Newsletter – July 2019 – Volume 19, Issue 7


CMS News

  • New, Revised, and Deleted HCPCS® Effective July 1, 2019
  • Quarterly ASP (Average Sales Price) Pricing File Released
  • Hospital OPPS (Outpatient Prospective Payment System) 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 21 AWP Drug Code Price changes this month, 6 (29%) 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:

  • J2274 Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 31%
  • S5010 5% Dextrose and 0.45% normal saline, 1000 mL 21%
  • J9395 Injection, fulvestrant, 25 mg 6%

Price Increases:

  • J1200 Injection, diphenhydramine HCl, up to 50 mg 14%
  • J0610 Injection, calcium gluconate, per 10 mL 50%
  • J2765 Injection, metoclopramide HCl, up to 10 mg 99%

CMS News:

New, Revised, and Deleted HCPCS® Effective July 1, 2019

CMS (Centers for Medicare & Medicaid Services) have released a set of new, revised, and deleted HCPCS® codes effective July 1, 2019.  The new codes are now appropriately crosswalked in our data for customers.

The American Medical Association (AMA) has also released recent changes to the CPT® Vaccine Codes, shown below. All new codes are currently available in our system.

The following is a list of codes are currently available and/or revised:

New HCPCS® Codes:

C9047 – Injection, caplacizumab-yhdp, 1 mg

C9048 – Dexamethasone, lacrimal ophthalmic insert, 0.1 mg

C9049 – Injection, tagraxofusp-erzs, 10 mcg

C9050 – Injection, emapalumab-lzsg, 1 mg

C9051 – Injection, omadacycline, 1 mg

C9052 – Injection, ravulizumab-cwvz, 10 mg

C9756 – Intraoperative near-infrared fluorescence lymphatic mapping for lymph node(s) (sentinel or tumor draining) with administration of indocyanine green (ICG) (List separately in addition to code for primary procedure)

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

New CPT® Codes:

90619-Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use

Revised HCPCS® Codes:


                Old Description: Injection, trastuzumab, 10 mg

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

Revised CPT® Codes:


                Old Description: Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MCV4 or MenACWY), for intramuscular use

                New Description: Meningococcal conjugate vaccine, serogroups A, C, W, Y,
quadrivalent, diphtheria toxoid carrier (MenACWY-D) or CRM197 carrier (MenACWY-CRM), for intramuscular use

Deleted HCPCS® Codes:

C9042 – Injection, bendamustine hcl (belrapzo), 1 mg

C9141 – Injection factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi), 1 i.u.

C9746 – Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed

J9031 – bCG (intravesical), per installation

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 July 1, 2019 through September 30, 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. Please note: Code(s) with revisions are noted in parenthesis.

July 2018 ASP Pricing File (Code: J7517)

October 2018 ASP Pricing File (Code: J7517)

January 2019 ASP Pricing File (Code: J7517)

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.”

Our data files and website have incorporated these changes. As a reminder, we display the most recent revised rate on the Medicare Allowable tab on the pricing screen. To view previous Medicare Allowable rates for a quarter (if revised), click on the appropriate Effective Date on the same screen. Please Note: ASP rate revisions are retroactive to the beginning of the quarter.

July 2019 NOC (Not Otherwise Classified) Pricing File:

CMS released the July 1, 2019 NOC Pricing file.

To view the NOC pricing file on the website, search on a NOC (Not Otherwise Classified) code, product or NDC and click on the link “Listing of CMS ASP+6% rates for NOCs” under Additional Information on the left side of the screen.

Hospital OPPS (Outpatient Prospective Payment System) Update:

If billing under the Hospital OPPS (Outpatient Prospective Payment System) the July 1, 2019 – September 30, 2019 APC rates are now available on the Pricing tab under APC. The APC tab will also provide you with the APC and Status Indicator (SI), if established.


This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 21 Drug Codes that required a recalculation of their AWP Code Price. There was a total of 109 Drug Codes that had a recalculation of their AWP Code Price due to our new updated pricing methodology. Log in to www.ReimbursementCodes.com to view the pricing updates for these codes:

A4215 J2274 J8530
A4247 J2597 J9050
B4161 J2765 J9060
J0610 J7120 J9260
J1200 J7190 J9395
J1627 J7307 J9600
J2060 J7606 S5010



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 one drug that required updating.


ZOLGENSMA® (onasemnogene abeparvovec-xioi) suspension, for intravenous infusionby AveXis, Inc.

PIQRAY® (alpelisib) tablets, for oral useby Novartis

POLIVY™ (polatuzumab vedotin-piiq) injection, for intravenous useby Genentech, Inc.



POLIVY™ (polatuzumab vedotin-piiq) injection, for intravenous useby Taiho Pharmaceutical Co., Ltd.

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


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

For more detailed information regarding the update Click Here.

View last month’s Newsletter


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