Specialty Drug Reimbursement – Newsletter – August 2020 – Volume 20, Issue 8


Drug Reimbursement Code Price Updates


      • New Clinical and Billing Information

    Clinical News

      • 2020-2021 Influenza Vaccine Season NDCs Now Available
      • J7304 Updated to NDC Level Pricing


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 75 AWP Drug Code Price changes this month, 20 (27%) 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:

  • J8521  Capecitabine, oral, 500 mg, 60%
  • J7609  Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg (Code Price is for active ingredient only and does not include compounding cost), 48%
  • J0604  Cinacalcet, oral, 1 mg, (for ESRD on dialysis) (For billing prior to 1/1/18 use J8499),36%

Price Increases:

  • J7611  Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg (Code reinstated effective 4/1/2008), 71%
  • S5012  5% dextrose with potassium chloride, 1000 mL, 62%
  • J3030  Injection, sumatriptan, succinate, 6 mg (code may be used for Medicare when drug administered under direct supervision of a physician; not for use when drug is self-administered), 39%

CMS News:

Check back next month for updates from Centers for Medicare and Medicaid (CMS).

Clinical News

2020-2021 Influenza Vaccine Season NDCs Now Available

New NDCs for the 2020-2021 Flu Season are cross-walked to their appropriate CPT codes and are now available on www.ReimbursementCodes.com   Click the following link for a comprehensive list of NDCs cross-walked this month: 2020-2021 Vaccine Flu Codes

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.

J7304 Updated to NDC Level Pricing

After an internal discussion by our clinical committee, it was decided to update J7304 to NDC level pricing now that a new product called Twirla® is available and cross-walked to this code. Appropriate reimbursement for this HCPCS® code will be based on NDC submitted.

Drug Reimbursement Code Price Updates:

This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 75 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.


90653 A4247 J0202 J1630 J7304 J8530 J9305
90674 A4614 J0490 J2182 J7326 J8700 J9308
90682 A9606 J0515 J2323 J7503 J9023 J9351
90685 B4153 J0517 J2783 J7606 J9042 Q0161
90686 B4157 J0604 J3030 J7609 J9043 Q4195
90687 B4158 J0641 J3243 J7611 J9055 Q4196
90688 B4160 J0878 J3250 J7614 J9171 Q4205
90739 B4162 J1030 J3316 J7677 J9173 Q4226
90756 C9488 J1170 J3489 J7686 J9204 S5012
A4216 J0121 J1190 J7042 J8515 J9206
A4245 J0185 J1439 J7060 J8521 J9269



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 that needed to be added to our database. Our review of existing drugs in our database with clinical and billing information already assigned identified six drugs that required updating.


UPLIZNA™ (inebilizumab-cdon) injection, for intravenous use – By Viela Bio, Inc.

ZEPZELCA™ (lurbinectedin) for injection, for intravenous use – By Jazz Pharmaceuticals, Inc.

PHESGO™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf) injection, for subcutaneous use – By Genentech, Inc.


DUPIXENT® (dupilumab) injection, for subcutaneous use – By Regeneron Pharmaceuticals, Inc.

ICLUSIG® (ponatinib) tablets, for oral use – By Takeda Pharmaceutical Company Limited

XPOVIO™ (selinexor) tablets, for oral use – By Karyopharm Therapeutics Inc.

TAZVERIK™ (tazemetostat) tablets, for oral use – By Epizyme, Inc.

COSENTYX® (secukinumab) for injection, for subcutaneous use – By Novartis Pharmaceuticals Corporation

KINERET® (anakinra) for injection, for subcutaneous use – By Swedish Orphan Biovitrum AB (publ)

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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