Specialty Drug Reimbursement – Newsletter – August 2020 – Volume 20, Issue 8

INSIDE THIS ISSUE

Drug Reimbursement Code Price Updates

Drugs/Devices

• • • New Clinical and Billing Information

  Clinical News

  • • 2020-2021 Influenza Vaccine Season NDCs Now Available
    • J7304 Updated to NDC Level Pricing

CODE UPDATES

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 75 AWP Drug Code Price changes this month, 20 (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.

LOOK UP PRICES NOW:

CMS News:

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

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 75 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.

LOOK UP PRICES NOW:

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 that needed to be added to our database. Our review of existing drugs in our database with clinical and billing information already assigned identified six drugs that required updating.

News:

UPLIZNA™ (inebilizumab-cdon) injection, for intravenous use – By Viela Bio, Inc.

ZEPZELCA™ (lurbinectedin) for injection, for intravenous use – By Jazz Pharmaceuticals, Inc.

PHESGO™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf) injection, for subcutaneous use – By Genentech, Inc.

Updated:

DUPIXENT® (dupilumab) injection, for subcutaneous use – By Regeneron Pharmaceuticals, Inc.

ICLUSIG® (ponatinib) tablets, for oral use – By Takeda Pharmaceutical Company Limited

XPOVIO™ (selinexor) tablets, for oral use – By Karyopharm Therapeutics Inc.

TAZVERIK™ (tazemetostat) tablets, for oral use – By Epizyme, Inc.

COSENTYX® (secukinumab) for injection, for subcutaneous use – By Novartis Pharmaceuticals Corporation

KINERET® (anakinra) for injection, for subcutaneous use – By Swedish Orphan Biovitrum AB (publ)

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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