Specialty Drug Reimbursement – Newsletter – February 2020 – Volume 20, Issue 2


Clinical News

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 224 AWP Drug Code Price changes this month, 28 (13%) 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:

  • J7509 Methylprednisolone, oral, per 4 mg, 73%
  • J0698 Cefotaxime sodium, per gram, 56%
  • J9245 Injection, melphalan hydrochloride, 50 mg, 41%

Price Increases:

  • J0171 Injection, adrenalin, epinephrine, 0.1 mg, 49%
  • Q4166 Cytal, per square centimeter, 46%
  • A4245 Alcohol wipes, per box (Code Price is per quantity of 100) (Code Price is based on median pricing methodology), 31%

CMS News:

Check back next month for any pertinent news or updates from CMS.

Clinical News

Each month the RJ Health Clinical Committee meets to review newly approved drugs, dosing, ICD-10 assignments, coding assignments and billable units. Additionally, we discuss questions and concerns our customers raise to ensure we are providing the most accurate and current information in our data and on our website.

Check back next month for any pertinent updates from our Clinical Committee.

Drug Reimbursement Code Price Updates:

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 224 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.

90291 90746 C9254 J0295 J0638 J1364 J1826 J2562 J3260 J7195 J8655 J9205 J9303 Q4166
90620 90747 C9290 J0461 J0642 J1410 J1885 J2590 J3262 J7200 J9022 J9209 J9305 Q5118
90621 90750 C9488 J0480 J0692 J1438 J1930 J2597 J3357 J7201 J9023 J9210 J9306 Q9957
90632 A4215 E0570 J0490 J0695 J1439 J1931 J2770 J3358 J7203 J9032 J9216 J9307 Q9991
90633 A4216 E0607 J0500 J0698 J1453 J1950 J2783 J3380 J7205 J9039 J9228 J9308 Q9992
90636 A4230 J0129 J0517 J0712 J1458 J2060 J2794 J3396 J7208 J9042 J9229 J9315 S0030
90648 A4231 J0131 J0558 J0717 J1555 J2170 J2796 J3471 J7297 J9043 J9245 J9325 S0093
90670 A4245 J0171 J0561 J0850 J1575 J2182 J2798 J3480 J7325 J9047 J9250 J9352 S0126
90675 A6010 J0180 J0567 J0875 J1602 J2212 J2941 J3486 J7504 J9055 J9260 J9354 S0128
90681 A6237 J0185 J0583 J0878 J1628 J2260 J3010 J7060 J7509 J9145 J9262 Q0138 S0157
90690 A9513 J0202 J0584 J0894 J1631 J2274 J3060 J7170 J7511 J9171 J9264 Q0139 S0176
90696 A9604 J0207 J0593 J0897 J1640 J2278 J3090 J7175 J7527 J9173 J9266 Q0175 S0182
90700 A9606 J0221 J0595 J1000 J1720 J2323 J3095 J7181 J7605 J9176 J9271 Q3027 S4991
90714 B4100 J0270 J0596 J1200 J1741 J2357 J3101 J7182 J7606 J9179 J9299 Q4132 S5010
90723 B4149 J0280 J0630 J1265 J1750 J2405 J3121 J7189 J7614 J9203 J9301 Q4133 S5571
90744 B4155 J0289 J0637 J1322 J1786 J2426 J3240 J7192 J7686 J9204 J9302 Q4148 S8490




Drugs/Devices: New/Updated Billing & Clinical Information

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 and three drugs that required updating.


AYVAKIT™ (avapritinib) tablets, for oral use – by Blueprint Medicines Corp.

ENHERTU® (fam-trastuzumab deruxtecan-nxki) for injection, for intravenous us e- by Daiichi Sankyo, Inc.  

PADCEV™ (enfortumab vedotin-ejfv) for injection, for intravenous use – by Seattle Genetics, Inc.

RECARBRIO™ (imipenem, cilastatin, and relebactam) for injection, for intravenous use – by Merck & Co., Inc.


CALQUENCE® (acalabrutinib) capsules, for oral use – by AstraZeneca Pharmaceuticals LP

OZEMPIC® (semaglutide) injection, for subcutaneous use – by Novo Nordisk

XELJANZ (tofacitinib) tablets, for oral use and XELJANZ® XR (tofacitinib) extended release tablets, for oral use – by Pfizer, Inc

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

View last month’s newsletter.

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