Specialty Drug Reimbursement – Newsletter – May 2020 – Volume 20, Issue 5


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 55 AWP Drug Code Price changes this month, 18 (33%) 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:

  • J3246  Injection, tirofiban HCl, 0.25 mg, 75%
  • Q0166 Granisetron hydrochloride, 1 mg oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen – see also S0091, 54%
  • S0091 Granisetron hydrochloride, 1 mg (for circumstances falling under the Medicare statute, use Q0166), 54%

Price Increases:

  • J2274   Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg, 42%
  • S0109  Methadone, oral, 5 mg, 24%
  • Q4117  Hyalomatrix, per square centimeter (Code Price is based on Median Pricing Methodology), 11%

CMS News:

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

Drug Reimbursement Code Price Updates:

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 55 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.

90694 J0599 J2543 J9032 Q4217
A4253 J0775 J2597 J9206 Q5112
A4256 J0878 J2795 J9207 S0091
A4614 J1644 J2800 J9225 S0106
A6248 J1790 J3110 J9226 S0109
A9521 J1943 J3145 J9307 S0137
A9543 J1944 J3230 J9315 S5571
A9569 J2175 J3246 J9371
B4103 J2270 J3420 J9395
J0185 J2274 J7507 Q0166
J0592 J2405 J7626 Q3028
J0597 J2440 J8540 Q4117



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 four drugs that required updating.


PEMAZYRE™ (pemigatinib) tablets, for oral use-by Incyte Corporation

TRODELVY™ (sacituzumab govitecan-hziy) for injection, for intravenous use-by Immunomedics, Inc.

TUKYSA™ (tucatinib) tablets, for oral use-by Seattle Genetics, Inc.


AKOVAZ™ (ephedrine sulfate injection, USP) for intravenous use-by Avadel Legacy Pharmaceuticals, LLC

DEFITELIO® (defibrotide sodium) injection, for intravenous use-by Jazz Pharmaceuticals, Inc

REBLOZYL® (luspatercept-aamt) for injection, for subcutaneous use-by Celgene Corporation

VERZENIO® (abemaciclib) tablets, for oral use-by Eli Lilly and 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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