Specialty Drug Reimbursement – Newsletter – August 2019 – Volume 19, Issue 8


CMS News

  • 2019-2020 Influenza Vaccine Season NDCs Now Available

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 87 AWP Drug Code Price changes this month, 20 (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:

  • Q4184 Cellesta, per square centimeter 69%
  • S0088 Imatinib,100 mg 63%
  • J1744 Injection, icatibant, 1 mg (For billing prior to 1/1/13 use J3490 or C9399) 54%

Price Increases:

  • J7322 Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg (Code re-used by CMS effective 1/1/17) (For billing prior to 1/1/17 use J3490 or C9471 for OPPS billing) (Hymovis dose is 24 mg/3 mL) (Note: Total dose regimen = 2 injections) 52%
  • J2690 Injection, procainamide HCl, up to 1 g 36%
  • J0637 Injection, caspofungin acetate, 5 mg 32%

CMS News:

2019-2020 Influenza Vaccine Season NDCs Now Available

New NDCs for the 2019-2020 Flu Vaccine Season are cross-walked to their appropriate CPT codes and are now available on ReimbursementCodes.com. Click here for a comprehensive list of NDCs crosswalked this month.


This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 87 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:

90653 A9543 J0278 J1626 J2690 J7674 J2228 Q9968
90662 A9606 J0282 J1631 J2720 J9015 J9271 S0088
90674 B4153 J0490 J1744 J2783 J9022 J9299 S0176
90682 B4157 J0517 J1940 J3090 J9023 J9301
90685 B4158 J0637 J2250 J3101 J9032 J9305
90686 B4160 J0641 J2323 J3262 J9042 J9306
90687 C9048 J0695 J2357 J3380 J9043 J9307
90688 G9017 J0878 J2405 J3396 J9055 J9308
90756 J0153 J1439 J2469 J3480 J9173 J9354
A4802 J0185 J1454 J2503 J7322 J9176 Q0138
A9537 J0202 J1555 J2507 J7503 J9179 Q0139
A9538 J0257 J1575 J2675 J7507 J9207 Q4184





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 one 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.


XPOVIO™ (selinexor) tablets, for oral useby Karyopharm Therapeutics Inc.



DUPIXENT® (dupilumab) injection, for subcutaneous useby Regeneron Pharmaceuticals, Inc.

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

GATTEX® (teduglutide) for injection, for subcutaneous useby Shire-NPS Pharmaceuticals, Inc.

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

NINLARO® (ixazomib) capsules, for oral useby Millennium Pharmaceuticals, Inc.

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

View last month’s Newsletter

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RJ Health is a drug data, application & analytics provider to the pharmacy reimbursement market, who brings scalability to specialty drug innovation. We focus on specialty drug innovation (new approvals and additional indications), as well as normalizing reimbursement for drug classifications that have market forces at-play (generics / biosimilars, rebates, and CMS policy). The company provides industry standard pricing, coding, dosing, weight, age, and diagnosis data & analyses to pharmacy, market access, claims, billing, finance, and network management clientele. RJ Health ensures transparency between manufacturer, payor, provider, pharmacies and their respective solution vendors (PBMs, Payment Integrity, Revenue Cycle, EHR, etc…) – all licensees of RJ Health data. 

Our tools and data:

Assist in understanding drug pricing and healthcare reimbursement for drug claims

Enable organizations to look up and crosswalk NDCs and HCPCS codes – J codes, C codes and other

 Assist in calculating drug dosage accurately and ensure claims are reimbursed properly based on unit requirements

Ensure claim accuracy and crosswalk drug codes

Help organizations make the best decisions for drug formularies

Combine clinical diagnosis and procedural coding matched to the right drug and dosage, as well as the most cost-efficient specialty drug price

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