Specialty Drug Reimbursement – Newsletter – September 2020 – Volume 20, Issue 9


Drug Reimbursement Code Price Updates


      • New Clinical and Billing Information

    CMS News

      • New HCPCS® Codes Effective 10/1/2020 Now Available
      • Deleted and Revised HCPCS® Coming Soon

    Clinical News

      • 2020-2021 Influenza Vaccine Season NDCs Now Available


    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 43 AWP Drug Code Price changes this month, 15 (43%) 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:

    • J2515 Injection, pentobarbital sodium, per 50 mg, 35%
    • J2469 Injection, palonosetron HCl, 25 mcg, 21%
    • J0456 Injection, azithromycin, 500 mg, 17%

    Price Increases:

    • Q4165 Keramatrix or kerasorb, per square centimeter (Code Price is based on Median Pricing Methodology), 178%
    • J1790 Injection, droperidol, up to 5 mg, 51%
    • B4100 Food thickener, administered orally, per ounce (Code Price is based on median pricing methodology), 41%

    CMS News:

    New HCPCS® Codes Effective October 1, 2020 Now Available

    CMS (Centers for Medicare & Medicaid Services) released their quarterly Alpha-Numeric HCPCS® File for October 2020. All new codes have been added to www.ReimbursementCodes.com  These codes become effective for Medicare billing for dates of service on and after October 1, 2020. Our system has been updated with the new codes one month in advance to allow for our customers to update their systems ahead of time.  Below is the complete list of new codes:

    C9060 Fluoroestradiol f18, diagnostic, 1 mci

    C9062 Injection, daratumumab 10 mg and hyaluronidase-fihj

    C9064 Mitomycin pyelocalyceal instillation, 1 mg

    C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg

    C9066 Injection, sacituzumab govitecan-hziy, 10 mg

    C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mci

    J1437 Injection, ferric derisomaltose, 10 mg

    J1632 Injection, brexanolone, 1 mg

    J1738 Injection, meloxicam, 1 mg

    J3032 Injection, eptinezumab-jjmr, 1 mg

    J3241 Injection, teprotumumab-trbw, 10 mg

    J7351 Injection, bimatoprost, intracameral implant, 1 microgram

    J9227 Injection, isatuximab-irfc, 10 mg

    J9304 Injection, pemetrexed (pemfexy), 10 mg

    Q4249 Amniply, for topical use only, per square centimeter

    Q4250 Amnioamp-mp, per square centimeter

    Q4254 Novafix dl, per square centimeter

    Q4255 Reguard, for topical use only, per square centimeter


    Deleted and Revised HCPCS® Coming Soon

    CMS released their quarterly Alpha-Numeric HCPCS® File for October 2020 which contains deleted and revised HCPCS® code changes effective October 1, 2020.  These changes will be made for our October release.  See below for a complete list of deleted and revised HCPCS® codes:

    Deleted HCPCS® Codes:

    C9055 Injection, brexanolone, 1mg

    C9059 Injection, meloxicam, 1 mg

    C9061 Injection, teprotumumab-trbw, 10 mg

    C9063 Injection, eptinezumab-jjmr, 1 mg

    Revised HCPCS® Codes:

    J9305 Current Description: Injection, pemetrexed, 10 mg

    J9305 Revised Description: Injection, pemetrexed, not otherwise specified, 10 mg

  • 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 43 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.

  • A4245 B4159 J1459 J9025 Q4246
    A4256 B4161 J1559 J9153 S0138
    A6248 B4162 J1569 J9201 S0190
    A9579 E0570 J1790 Q4165
    B4100 E0607 J2260 Q4196
    B4103 J0256 J2405 Q4227
    B4150 J0257 J2469 Q4234
    B4152 J0456 J2515 Q4237
    B4154 J0692 J2543 Q4238
    B4155 J0770 J2597 Q4239


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


    BLENREP (belantamab mafodotin-blmf) for injection, for intravenous use – By GlaxoSmithKline Intellectual Property Development Ltd. England

    ENSPRYNG™ (satralizumab-mwge) injection, for subcutaneous use – By Genentech, Inc.

    MONJUVI® (tafasitamab-cxix) for injection, for intravenous use – By Morphosys US Inc.

    VICTOZA®(liraglutide) injection, for subcutaneous use – By Novo Nordisk

    TECARTUS™ (brexucabtagene autoleucel) suspension, for intravenous infusion – By Kite Pharma, Inc.


    IDHIFA® (enasidenib) tablets, for oral use-By Celgene Corporation

    • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

    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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