Specialty Drug Reimbursement – Newsletter – May 2021 – Volume 21, Issue 5


Drug Reimbursement Code Price Updates


-New Clinical and Billing Information

CMS News

Clinical News

-Removal of NOC flag from J1599 and reinstatement of code price coming next month


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 71 AWP Drug Code Price changes this month, 21 (30%) 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:

  • J1940   Injection, furosemide, up to 20 mg, 25%
  • J2469   Injection, palonosetron HCl, 25 mcg, 25%
  • S0179   Megestrol acetate, oral 20 mg, 25%

Price Increases:

  • J0698   Cefotaxime sodium, per gram, 275%
  • Q4140  BioDFence, per square centimeter (Code Price based on Median pricing methodology), 43%
  • J2001   Injection, lidocaine HCL for intravenous infusion, 10 mg, 25%

CMS News

Check back next month for any pertinent updates from CMS.

See previous updates.

  • 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.

Removal of NOC flag from J1599 and reinstatement of code price coming next month

The committee met internally this month regarding the crosswalk for J1599 – Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg.  This HCPCS code is currently flagged as a Not Otherwise Classified (NOC) code in our data.  However, now that Panzyga is the only drug cross-walked to this code, it was determined that a code price should be reinstated for our June 1 update. This will also cause this HCPCS to move from the NOC tab to the NDC crosswalk tab in our data files as well. We are notifying clients one month ahead of time to prepare for this change.

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 71 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.

  • 90378

    E0607 J1940 J7040 J9307 Q4138


    J0185 J1943 J7050 J9371 Q4140


    J0221 J2001 J7060 Q0161 Q4148


    J0278 J2310 J7070 Q2041 Q4155


    J0360 J2315 J7314 Q2050 Q4156


    J0693 J2469 J8520 Q2053 Q4166
    B4103 J0698 J2543 J8521 Q4104


    B4150 J0775 J2597 J9032 Q4105


    B4185 J0834 J2786 J9171 Q4108


    C9353 J1301 J3145 J9177 Q4110


    C9356 J1652 J3380 J9226 Q4114


    C9363 J1790 J3410 J9271




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


    ABECMA™ (idecabtagene vicleucel), suspension for intravenous infusion – By Celgene Corporation

    FOTIVDA® (tivozanib) capsules, for oral use – By AVEO Pharmaceuticals, Inc.

    LYSODREN® (mitotane) tablets, for oral use – By Corden Pharma Latina S.p.A.


    LORBRENA® (lorlatinib) tablets, for oral use – By Pfizer

    PRALUENT® (alirocumab) injection, for subcutaneous use – By Regeneron Pharmaceuticals, Inc.

    TYMLOS® (abaloparatide) injection, for subcutaneous use – By Radius Health, Inc.

    ZYPREXA IntraMuscular (olanzapine) Injection, Powder, For Solution for Intramuscular useBy Lilly USA

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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