Specialty Drug Reimbursement – Newsletter – November 2020 – Volume 20, Issue 11


Drug Reimbursement Code Price Updates


      • New Clinical and Billing Information

    CMS News

    Clinical 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 63 AWP Drug Code Price changes this month, 17 (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:

    • S0169  Calcitriol, 0.25 microgram, 67%
    • A7005  Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable (Code Price is based on median pricing methodology), 58%
    • Q0177 Hydroxyzine pamoate, 25 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment, not to exceed a 48-hour dosage regimen (Indication not FDA-approved at this time), 40%

    Price Increases:

    • A7015 Aerosol mask, used with DME nebulizer (Code Price is based on median pricing methodology), 104%
    • J1200 Injection, diphenhydramine HCl, up to 50 mg, 49%
    • J2795 Injection, ropivacaine hydrochloride, 1 mg, 44%

    CMS News:

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

  • Clinical News

    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.

See news from previous months.

  • Drug Reimbursement Code Price Updates:

    This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 63 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.

    A4215 C9488 J1162 J3145 J9226 S0169
    A4253 E0570 J1200 J3380 J9271 S0170
    A4256 E0607 J1301 J7178 J9313 S4991
    A4259 J0185 J1557 J7180 J9395
    A6025 J0360 J1627 J7187 Q0138
    A6248 J0364 J1644 J7202 Q0139
    A7005 J0594 J2060 J7210 Q0177
    A7015 J0604 J2786 J8520 Q4196
    A9589 J0641 J2795 J9177 Q4254
    B4103 J0692 J2800 J9185 Q9967
    C9132 J0775 J2860 J9202 S0088
    C9293 J0878 J3095 J9225 S0136


    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 four new drugs which needed to be added to our database and two drugs that required updating.


    FETROJA® (cefiderocol) for injection, for intravenous use – By Shionogi Inc.

    VISTASEAL™ [Fibrin Sealant (Human)] – By Instituto Grifols, S.A

    OTREXUPTM (methotrexate) injection, for subcutaneous use – By Antares Pharma, Inc.


    PALYNZIQ® (pegvaliase-pqpz) injection, for subcutaneous use – By BioMarin Pharmaceutical

    VENCLEXTA® (venetoclax tablets), for oral use By AbbVie Inc.

Our Resources

Learn more – RJ Health Resources

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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