Specialty Drug Reimbursement – Newsletter – December 2020 – Volume 20, Issue 12


Drug Reimbursement Code Price Updates


-New Clinical and Billing Information

CMS News

-2021 HCPCS® File

-Coronavirus Vaccines and Treatment Response

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 39 AWP Drug Code Price changes this month, 17 (44%) 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:

  • A9575 Injection, gadoterate meglumine, 0.1 mL, 29%
  • J1200  Injection, diphenhydramine HCl, up to 50 mg, 27%
  • J0604  Cinacalcet, oral, 1 mg, (for ESRD on dialysis) (For billing prior to 1/1/18 use J8499), 24%

Price Increases:

  • J7329   Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg, 166%
  • B4149  Enteral formula, manufactured blenderized natural foods with intact nutrients includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 cals = 1 unit (Code Price is per 100 calories and is based on median pricing methodology), 20%
  • J0285  amphotericin B, 50mg, 10%

CMS News:

The 2021 HCPCS® File

The 2021 HCPCS® file was not released by Centers for Medicare and Medicaid Services (CMS) in time for the December update. It is expected to be released next month and will be available in the January update.

Coronavirus Vaccines and Treatment Response

Coronavirus vaccines are currently going through development and approval processes, as well as the antibody treatment, Bamlanivimab. In anticipation of approval for use, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have released new CPT® and HCPCS ®codes. These codes are listed below:

91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

(Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein,

preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use

91301 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

(Coronavirus disease [COVID-19]) vaccine, mRNA-LNP,

spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use

Q0239 Injection, bamlanivimab-xxxx, 700 mg

All three of these codes have been added to our data in preparation for upcoming reimbursement when each product is approved and released. These codes do have NDC(s) cross walked, however, we have not established code level prices as the current NDC(s) do not currently have prices reported. We currently recommend NDC level pricing for the most accurate reimbursement. For further information please refer to the code alerts on the corresponding drug cards on www.ReimbursementCodes.com. This is a developing situation, and we will continuously monitor for updates and make changes accordingly for each monthly update.

  • 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.

    90632 90732 B4152 J1200 J7329
    90633 90744 E0570 J1453 J7507
    90647 A4259 E0607 J1650 J8700
    90651 A7003 J0131 J2920 S0028
    90680 A7005 J0285 J2930 S0092
    90707 A9575 J0604 J2993 S0136
    90710 B4103 J0878 J3486 S4991
    90716 B4149 J1071 J7315


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


    OLINVYK™ (oliceridine) injection, for intravenous use, CII – By Trevena, Inc.

    REDITREX™ (methotrexate) injection, for subcutaneous use – By Cumberland Pharmaceuticals Inc.


    VALCHLOR® (mechlorethamine) gel, for topical use – By Helsinn Therapeutics, (U.S.), Inc.

    XTANDI® (enzalutamide) capsules, for oral use; XTANDI® (enzalutamide) tablets, for oral use – By Astellas Pharma US, 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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