Specialty Drug Reimbursement – Newsletter – February 2021 – Volume 21, Issue 2


Drug Reimbursement Code Price Updates


-New Clinical and Billing Information

CMS News

-New CPT® Codes Now Available for COVID Vaccines

Clinical News

-Spravato® Code Price Update


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 192 AWP Drug Code Price changes this month, 21 (11%) 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:

  • J0894   Injection, fulvestrant, 1 mg, 39%
  • Q0163  Diphenhydramine hydrochloride, 50 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 Price is per 50 mg), 33%
  • J0171   Injection, adrenalin, epinephrine, 0.1 mg, 25%

Price Increases:

  • A7005   Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable (Code Price is based on median pricing methodology, 202%
  • Q4176   Neopatch or therion, per square centimeter (Code Price is based on Median Pricing Methodology, 140%
  • A7003   Administration set, with small volume nonfiltered pneumatic nebulizer, disposable (Code Price based on median pricing methodology), 92%

CMS News:

Coronavirus Vaccines and Treatment Response

Coronavirus vaccines are currently going through development and approval processes. With the approval of more vaccines, the American Medical Association (AMA) have released new CPT® codes. These codes are listed below:

87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual)

observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

(Coronavirus disease [COVID-19]) (NDC level pricing reflects cost of testing kit only)




Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2)

(coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1

 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use


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

(coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector,

preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use

All 3 of these codes have been added to our data. 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.

Spravato® Code Price Update

After internal discussion and discussions with the manufacturer of Spravato it was decided we will be providing a code price for S0013: Esketamine, nasal spray, 1 mg. We have updated our data to represent a code price that reflects the pricing of the product per mg. This price will be retroactive from January 1st, when the code became effective. Please review the website for further information.

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 192 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.

    90620 A7005 J0490 J1410 J2323 J7183 J8520 J9301
    90621 A7015 J0517 J1439 J2350 J7185 J8655 J9305
    90632 A9606 J0567 J1454 J2357 J7189 J8700 J9306
    90633 B4103 J0584 J1458 J2425 J7192 J9022 J9308
    90636 B4149 J0596 J1555 J2426 J7195 J9023 J9317
    90648 B4150 J0597 J1561 J2502 J7200 J9042 J9352
    90670 B4153 J0598 J1566 J2562 J7201 J9043 J9354
    90675 B4154 J0599 J1569 J2597 J7203 J9055 J9358
    90681 B4157 J0604 J1575 J2783 J7204 J9057 Q0138
    90696 B4158 J0630 J1602 J2794 J7205 J9144 Q0139
    90700 B4161 J0638 J1628 J2798 J7208 J9145 Q0163
    90715 B4162 J0712 J1640 J2941 J7209 J9150 Q0175
    90723 C9254 J0716 J1750 J3031 J7211 J9171 Q3027
    90734 E0570 J0717 J1786 J3060 J7296 J9176 Q3028
    90744 E0607 J0742 J1826 J3101 J7297 J9179 Q4176
    90750 J0121 J0791 J1833 J3240 J7298 J9203 Q9991
    A4208 J0129 J0875 J1930 J3357 J7301 J9204 Q9992
    A4209 J0171 J0878 J1931 J3358 J7508 J9205 S0013
    A4215 J0185 J0894 J1950 J3385 J7511 J9206 S0088
    A4256 J0257 J0896 J1953 J3397 J7517 J9227 S0126
    A4259 J0270 J1290 J2170 J3471 J7525 J9228 S0128
    A4614 J0289 J1322 J2182 J7170 J7605 J9229 S0182
    A6196 J0290 J1325 J2212 J7181 J7606 J9264 S0194
    A7003 J0401 J1327 J2250 J7182 J7677 J9299 S8490


    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 four drugs that required updating.


    RIABNI™ (rituximab-arrx) injection, for intravenous use – By Amgen, Inc.

    ORGOVYX (relugolix) tablets, for oral useMyovant Sciences, Inc.


    AGRISSO®(osimertinib) tablets, for oral us – By Astra Zeneca

    ICLUSIG® (ponatinib) tablets, for oral useBy ARIAD Pharmaceuticals, Inc.

    GAVRETO™ (pralsetinib) capsules, for oral useBy Blueprint Medicines Corporation

    XALKORI® (crizotinib) capsules, for oral useBy Pfizer Labs

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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