Specialty Drug Reimbursement – Newsletter – June 2020 – Volume 20, Issue 6


Drug Reimbursement Code Price Updates


      • New Clinical and Billing Information

    CMS News

      • New, Revised, and Deleted HCPCS® Effective July 1, 2020


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 26 AWP Drug Code Price changes this month, 16 (62%) 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:

  • S5551  Insulin, most rapid onset (Lispro or Aspart); 5 units (Code Price is based on median pricing methodology), 31%
  • J8610 Methotrexate, oral, 2.5 mg, 25%
  • J1626 Injection, granisetron hydrochloride, 100 mcg, 25%

Price Increases:

  • C9482 Injection, sotalol hydrochloride, 1 mg (For Hospital OPPS billing prior to 10/1/16 use C9399)
    – see also J3490, 60%
  • S0109  Methadone, oral, 5 mg, 29%
  • 90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen
    content, for intramuscular use (Fluzone High-Dose is only indicated for those 65 years of age and older)
    (Effective 6/1/2020 code Price is per 0.7 mL = 1 dose), 9%

CMS News:

New, Revised, and Deleted HCPCS® Effective July 1, 2020

CMS (Centers for Medicare & Medicaid Services) have released a set of new, revised, and deleted HCPCS® codes effective July 1, 2020.  These codes will become billable on July 1st.  The following is a list of codes that will be available and/or revised.

New HCPCS® Codes:

J0223    Injection, givosiran, 0.5 mg

J0591    Injection, deoxycholic acid, 1 mg

J0691    Injection, lefamulin, 1 mg

J0742    Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg

J0791    Injection, crizanlizumab-tmca, 5 mg

J0896    Injection, luspatercept-aamt, 0.25 mg

J1201    Injection, cetirizine hydrochloride, 0.5 mg

J1429    Injection, golodirsen, 10 mg

J1558    Injection, immune globulin (xembify), 100 mg

J3399    Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5×10^15 vector genomes

J7169    Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg

J7204    Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu

J7333    Hyaluronan or derivative, visco-3, for intra-articular injection, per dose

J9177    Injection, enfortumab vedotin-ejfv, 0.25 mg

J9198    Injection, gemcitabine hydrochloride, (infugem), 100 mg

J9246    Injection, melphalan (evomela), 1 mg

J9358    Injection, fam-trastuzumab deruxtecan-nxki, 1 mg

Q4227   Amniocore, per square centimeter

Q4228   Bionextpatch, per square centimeter

Q4229   Cogenex amniotic membrane, per square centimeter

Q4230   Cogenex flowable amnion, per 0.5 cc

Q4231   Corplex p, per cc

Q4232   Corplex, per square centimeter

Q4233   Surfactor or nudyn, per 0.5 cc

Q4234   Xcellerate, per square centimeter

Q4235   Amniorepair or altiply, per square centimeter

Q4236   Carepatch, per square centimeter

Q4237   Cryo-cord, per square centimeter

Q4238   Derm-maxx, per square centimeter

Q4239   Amnio-maxx or amnio-maxx lite, per square centimeter

Q4240   Corecyte, for topical use only, per 0.5 cc

Q4241   Polycyte, for topical use only, per 0.5 cc

Q4242   Amniocyte plus, per 0.5 cc

Q4244   Procenta, per 200 mg

Q4245   Amniotext, per cc

Q4246   Coretext or protext, per cc

Q4247   Amniotext patch, per square centimeter

Q4248   Dermacyte amniotic membrane allograft, per square centimeter

Q5119   Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg

Q5120   Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg

Q5121   Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

U0003   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, making use of high throughput technologies as described by  cms-2020-01-r

U0004   2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r


Revised HCPCS® Codes:


Old Description: Hyaluronan or derivative, Hyalgan or Supartz or Visco-3, for intra-articular injection, per dose (Hyalgan dose is 20 mg/2 mL, Supartz and Visco-3 dose is 25 mg/2.5 mL) (Note: Total dose regimen = 3 – 5 injections)

New Description: Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose



Old Description: Injection, melphalan hydrochloride, 50 mg

New Description: Injection, melphalan hydrochloride, not otherwise specified, 50 mg



Old Description: NeoPatch, per square centimeter

New Description: Neopatch or therion, per square centimeter


Deleted HCPCS® Codes:

J9199  Injection, gemcitabine hydrochloride (infugem), 200 mg

There has been an update of the Hospital Outpatient Prospective Payment System (OPPS) through the addition and deletion of new HCPCS® Codes. These codes will be effective July 1st. The following is a list of codes which will be available, discontinued and/or revised for the July update:

New HCPCS® Codes:

C1748  Endoscope, single-use (i.e. disposable), upper gi, imaging/illumination device (insertable)

C1849  Skin substitute, synthetic, resorbable, per square centimeter

C9059  Injection, meloxicam, 1 mg

C9061  Injection, teprotumumab-trbw, 10 mg

C9063  Injection, eptinezumab-jjmr, 1 mg

C9122  Mometasone furoate sinus implant, 10 micrograms (sinuva)

C9803  Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus  2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source

Deleted HCPCS® Codes:

C9041   Injection, coagulation factor xa (recombinant), inactivated (andexxa), 10 mg

C9053   Injection,  crizanlizumab-tmca, 1 mg

C9054   Injection, lefamulin (xenleta), 1 mg

C9056   Injection, givosiran, 0.5 mg

C9057   Injection, cetirizine hydrochloride, 1 mg

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

Drug Reimbursement Code Price Updates:

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 26 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.


J8610 C9482 J1110 Q9961 WW068


J8700 E0570 J1626 S0109


J9190 E0607 J1817


A4357 J9260 J0153 Q4206


A6196 Q0169 J0744 Q9960




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 seven new drugs which needed to be added to our database and one drug that required updating.


DARZALEX FASPRO™ (daratumumab and hyaluronidase-fihj) injection, for subcutaneous use – by Janssen Biotech, Inc.

TABRECTATM (capmatinib) tablets, for oral use – by: Novartis Pharmaceuticals Corp

RETEVMOTM (selpercatinib) capsules, for oral useBy: Eli Lilly and Company

REMDESIVIR (GS-5734™) for injection, for intravenous use – By: Gilead

DURYSTATM (bimatoprost implant), for intracameral administration By: Allergan

JELMYTO™ (mitomycin) for pyelocalyceal solution – By: UroGen Pharma, Inc.

QINLOCK™ (ripretinib) tablets, for oral use – By: Deciphera Pharmaceuticals, LLC


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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