Specialty Drug Reimbursement – Newsletter – April 2020 – Volume 20, Issue 4


Drug Reimbursement Code Price Updates


    • New Clinical and Billing Information

CMS News

    • New HCPCS® Codes Effective April 1, 2020 Now Available
    • Quarterly ASP (Average Sales Price) File Released
    • Hospital OPPS (Outpatient Prospective Payment System) Update
    • April 2020 NOC (Not Otherwise Classified) Pricing File Released


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 65 AWP Drug Code Price changes this month, 31 (48%) 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:

  • J8520   Capecitabine, oral, 150 mg, 39%
  • J0637   Injection, caspofungin acetate, 5 mg, 35%
  • E2100   Blood glucose monitor with integrated voice synthesizer (Code Price is based on median pricing methodology), 27%

Price Increases:

  • B4105  In-line cartridge containing digestive enzyme(s) for enteral feeding, each, 52%
  • Q4159  Affinity, per square centimeter, 167%
  • J1885   Injection, ketorolac tromethamine, per 15 mg, 27%

CMS News:

New HCPCS® Codes Effective April 1, 2020 Now Available

CMS (Centers for Medicare & Medicaid Services) released their quarterly Alpha-Numeric HCPCS® File for April 2020. All new codes have been added to ReimbursementCodes.com and are now effective. These drug codes became effective for Medicare billing for dates of service on and after April 1, 2020.  Below is the complete list of new codes:

C9053 – Injection, crizanlizumab-tmca, 1 mg

C9056 – Injection, givosiran, 0.5 mg

C9057 – Injection, cetirizine hydrochloride, 1 mg

C9058 – Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo) 0.5 mg


The American Medical Association (AMA) has also released a new CPT® code effective March 13, 2020 shown below. This new code is currently available on ReimbursementCodes.com

87635 – Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique


Quarterly ASP (Average Sales Price) File Released:

Another quarter has passed, and this means CMS has released the 2020 ASP pricing and revisions file. These rates are effective April 1, 2020 through June 30, 2020. 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.

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.”

CMS recently provided notification that the following quarters had revisions to the ASP pricing file. Please note: Code(s) with revisions are noted in parenthesis.

October 2019 ASP Pricing File (Codes: J1561, J1572, J1642, J2505)

January 2020 ASP Pricing File (Codes: J1453, J2505)

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.


Hospital OPPS (Outpatient Prospective Payment System) Update:

If billing under the Hospital OPPS (Outpatient Prospective Payment System) the April 1, 2020 – June 30, 2020 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.


April 2020 NOC (Not Otherwise Classified) Pricing File Released:

CMS released the April 1, 2020 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.

Drug Reimbursement Code Price Updates:

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 65 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.

90396 B4102 J0290 J3489 Q4105
A4215 B4103 J0637 J7186 Q4108
A4216 B4105 J0878 J7194 Q4110
A4217 B4157 J1644 J7304 Q4114
A4230 B4159 J1746 J7502 Q4159
A4231 B4162 J1885 J7527 S0030
A4245 C9248 J2185 J8520 S0088
A4253 C9358 J2250 J8700 S0122
A4256 C9360 J2270 J9025 S0156
A4407 C9363 J2310 J9190 S0194
A4414 E0570 J2405 Q0175 S5010
A4425 E0607 J3010 Q2043 S5012
A5063 E2100 J3486 Q4104 S5551



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 three new drugs which needed to be added to our database and six drugs that required updating.


SARCLISA® (isatuximab-irfc) injection, for intravenous use – by Sanofi-Aventis

VYEPTITM (eptinezumab-jjmr) injection, for intravenous use – by: Lundbeck Seattle Biopharmaceuticals, Inc.

ANJESO™ (meloxicam) injection, for intravenous use – by: Baudax Bio, Inc.


SYMLIN® (pramlintide acetate) injection for subcutaneous use – by AstraZeneca Pharmaceuticals

NERLYNX® (neratinib) tablets, for oral use – by Puma Biotechnology, Inc.

ALUNBRIG® (brigatinib) tablets, for oral use – by: Takeda Pharmaceutical Company Limited

MYALEPT® (metreleptin) for injection for subcutaneous use – by: Aegerion Pharmaceuticals

PRAXBIND® (idarucizumab) injection, for intravenous use – by: Boehringer Ingelheim Pharmaceuticals, Inc.

TIBSOVO® (ivosidenib tablets), for oral use – by: Agios Pharmaceuticals, 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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