Specialty Drug Reimbursement – Newsletter – April 2021 – Volume 21, Issue 4


Drug Reimbursement Code Price Updates


-New Clinical and Billing Information

CMS News

-New HCPCS® Codes Effective April 1, 2021 Now Available

-New HCPCS® Codes Adds, Deletes and Revisions Effective April 1, 2021 Now Available

-Quarterly ASP (Average Sales Price) File Released

-Hospital OPPS (Outpatient Prospective Payment System) Update

-April 2021 NOC (Not Otherwise Classified) Pricing File Released

Clinical News

-Biosimilar Crosswalk

-Clorotekal Code Placement


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 60 AWP Drug Code Price changes this month, 29 (48%) 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:

  • J0706   Injection, caffeine citrate, 5 mg, 52%
  • Q0161  Chlorpromazine hydrochloride, 5 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 (Code re-used by CMS 1/1/14), 36%
  • J8530   Cyclophosphamide, oral, 25 mg, 33%

Price Increases:

  • J2270  Injection, morphine sulfate, up to 10 mg (Code Price is per 10 mg), 16%
  • J9216  Injection, interferon, gamma-1b, 3 million units, 15%
  • J1270  Injection, doxercalciferol, 1 mcg, 14%

CMS News

New, Revised, and Deleted HCPCS® Codes Now Available

CMS (Centers for Medicare & Medicaid Services) released their annual HCPCS® File for April 2021 which includes all New, Deleted, and Revised HCPCS® Codes. New codes have been added to www.ReimbursementCodes.com  These codes became effective for Medicare billing for dates of service on and after April 1, 2021. Below is the list of new, deleted, and revised HCPCS® codes that RJ Health maintains in their database:

New HCPCS® Codes:

A9592 – Copper Cu-64, dotatate, diagnostic, 1 millicurie

C9074 – Injection, lumasiran, 0.5 mg

J1427 – Injection, viltolarsen, 10 mg

J1554 – Injection, immune globulin (asceniv), 500 mg

J7402 – Mometasone furoate sinus implant, (sinuva), 10 micrograms

J9349 – Injection, tafasitamab-cxix, 2 mg

Q2053 – Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose (Code Price is for drug only)

S1091 – Stent, non-coronary, temporary, with delivery system (propel)

J9037 – Injection, belantamab mafodontin-blmf, 0.5 mg


Deleted HCPCS® Codes

C9068 – Copper cu-64, dotatate, diagnostic, 1 millicurie

C9069 – Injection, belantamab mafodontin-blmf, 0.5 mg

C9070 – Injection, tafasitamab-cxix, 2 mg

C9071 – Injection, viltolarsen, 10 mg

C9072 – Injection, immune globulin (asceniv), 500 mg

C9073 – Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

C9122 – Mometasone furoate sinus implant, 10 micrograms (sinuva)

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

J7401 – Mometasone furoate sinus implant, 10 micrograms


Revised HCPCS® Codes


Updated Description: Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose    

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


Quarterly ASP (Average Sales Price) File Released:

Another quarter has passed, and this means CMS has released the April 2021 ASP pricing and revisions files. These rates are effective April 1, 2021 through June 30, 2021. This new ASP pricing file is incorporated in our own data and website. To view the most recent revised rates simply click on the Medicare Allowable tab on the pricing screen.  Please note: Code(s) with revisions are noted in parenthesis.

January 2021 ASP Pricing File (Codes: J2515, J7182, J9185, J9357, Q4074)

October 2020 ASP Pricing File (Codes: J0475, J0476, J0692, J7182, J8501, J9395, Q4074)

July 2020 ASP Pricing File (Codes: J9271, Q5104)

April 2020 ASP Pricing File (Codes: J2353, J9271, Q5104)

As per CMS, “the payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufacturers. The quarter to quarter price changes are generally the result of updated data from the manufacturers of these drugs.”

Our data files and website have incorporated these changes. As a reminder, we display the most recent revised rate on the Medicare Allowable tab on the pricing screen. To view previous Medicare Allowable rates for a quarter (if revised), click on the appropriate Effective Date on the same screen. Please Note: ASP rate revisions are retroactive to the beginning of the quarter.


April 2021 NOC (Not Otherwise Classified) Pricing File 

CMS released the April 1, 2021 NOC Pricing file.

To view the NOC pricing file on the website, search on a NOC (Not Otherwise Classified) code, product or NDC and click on the link “Listing of CMS ASP+6% rates for NOCs” under Additional Information on the left side of the screen.


Hospital OPPS (Outpatient Prospective Payment System) Update:

If billing under the Hospital OPPS (Outpatient Prospective Payment System) the April 1, 2021 – June 30, 2021 APC rates are now available on the Pricing tab under APC. The APC tab will also provide you with the APC and Status Indicator (SI), if established.

  • 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.

Clorotekal Code Placement

Our clinical committee reassessed the coding of Clorotekal this past month due to the development of new information provided and the reference crosswalking by CMS of this product to J2400, in their ASP Pricing File.  It was decided both Clorotekal NDCs will be removed from the NOC codes and placed in J2400: Injection, chloroprocaine hydrochloride, per 30 mL (Code Price is based on Median Pricing Methodology). This update will be made available April 1.


Biosimilar Crosswalk

With so many biosimilar products available on the market our clinical team decided it was best to create a crosswalk organizing biosimilars with their reference drugs. We hope this crosswalk will be able to clear up any confusions our clients may have about biosimilars and be a great reference. To view the crosswalk please click on the link below.

Biosimilar Drugs and their Associated Reference Drug PDF

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 60 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.

  • 90739

    B4162 J0696 J2400 J8521 Q4132


    C9248 J0698 J2469 J8530 Q4249


    C9482 J0706 J2700 J9017 S0028


    E0570 J0878 J3475 J9025 S0088


    E0607 J1040 J3489 J9027 S0166
    A4256 J0131 J1165 J7040 J9120


    A4259 J0133 J1327 J7050 J9171


    B4103 J0153 J1450 J7507 P9047


    B4153 J0295 J1746 J7517 Q0161


    B4161 J0604 J2060 J8520 Q2043




    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 three drugs that required updating.


    MARGENZATM (margetuximab-cmkb) injection, for intravenous use – By MacroGenics, Inc

    AMONDYS 45 (casimersen) injection, for intravenous use – By Sarepta Therapeutics, Inc.

    NULIBRYTM (fosdenopterin) for injection, for intravenous use – By Alcami Carolinas Corporation

    PEPAXTO® (melphalan flufenamide) for injection, for intravenous use – By Oncopeptides Inc.

    BIORPHEN® (phenylephrine hydrochloride) injection, for intravenous use – By Eton Pharmaceuticals, Inc


    SEVOFLURANE- sevoflurane liquid, aerosol – By Ferring

    NINLARO® (ixazomib) capsules, for oral use – By Millennium Pharmaceuticals, Inc.

    VOTRIENT® (pazopanib) tablets, for oral use By Novartis Pharmaceuticals Corporation

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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