Specialty Drug Reimbursement – Newsletter – March 2020 – Volume 20, Issue 3


Clinical News

    • Retroactive Pricing Issued for Q2043

Drug Reimbursement Code Price Updates


    • New Clinical and Billing Information

CMS News


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 52 AWP Drug Code Price changes this month, 21 (40%) 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:

  • J0282  Injection, amiodarone hydrochloride, 30 mg, 6%
  • J9025  Injection, azacitidine, 1 mg, 4%
  • J9171  Injection, docetaxel, 1 mg, 3%

Price Increases:

  • J7626   Budesonide, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, up to 0.5 mg, 85%
  • Q4158  Kerecis Omega3, per square centimeter (Code Price is based on Median Pricing Methodology),167%
  • A4455  Adhesive remover or solvent (for tape, cement or other adhesive), per oz., 152%

CMS News:

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

Clinical News

Retroactive Pricing Issued for Q2043

RJ Health is issuing retroactive pricing data for Q2043 – Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Code Price is per 250 mL) dating back to November 2019.  Our data reflects this update in both November 2019 and March 2020 pricing records. Please update your systems accordingly.

Drug Reimbursement Code Price Updates:

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 52 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.


J9025 J2502 S0132


J9171 J9019 J1568


S0119 J9175


S0030 A6203 E0607



A4427 A4367 Q0166
S0183 A6248 J3031



B4153 A4253



B4103 J2507



Q2043 J0716



A6196 J3110



J0583 A5054



J9206 J1644


J0282 J3397 A4398




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 five drugs that required updating.


PALFORZIA [Peanut (Arachis hypogaea) Allergen Powder-dnfp] Powder for oral administration – by Aimmune Therapeutics, Inc.

RUXIENCE™ (rituximab-pvvr) injection, for intravenous use – by Pfizer

TAZVERIKTM (tazemetostat) tablets, for oral use – by Epizyme, Inc.

TEPEZZA (teprotumumab-trbw) for injection, for intravenous use – by Horizon Therapeutics Ireland DAC


COSENTYX® (secukinumab) for injection, for subcutaneous use – by Novartis Pharmaceuticals Corp.

LYNPARZA® (olaparib) tablets, for oral use – by AstraZeneca Pharmaceuticals LP

OVIDREL® (choriogonadotropin alfa for injection) for subcutaneous use – by Serono, Inc.

UNITUXIN™ (dinutuximab) injection, for intravenous use – by United Therapeutics Corp.

GIAPREZA™ (angiotensin II) Injection for Intravenous Infusion – by La Jolla Pharmaceutical Company

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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