EmblemHealth Fee Schedule for Injectables and Other In-Office Medications (applies to plans underwritten by GHI, HIP and HIPIC)

Date Issued: 12/8/2014

The GHI, HIP and HIPIC network fee schedule for injectables and other medications rendered in the office setting are reimbursed based on the following methodology:

Maximum Allowable Cost (MAC): Utilized for select therapeutic categories where there is a clinically equivalent lower cost alternative available. The MAC is applied to the lower cost alternative product.

Average Sales Price (ASP) plus 10%: Utilized for drugs with an ASP available that are not included in the MAC category or a vaccine.

Average Wholesale Price (AWP) minus 10%: Utilized for vaccines and drugs that do not have an ASP or MAC available except for implants and contraceptives.

AWP: Utilized for all implants and contraceptives.

J-codes for injectables and other in-office medications priced at MAC are listed in the table below.

Code Description
J0640 Injection, leucovorin calcium, per 50 mg
J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg
J1557 Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg (For billing prior to January 1, 2012, use 90283, J1599 or C9270)
J1561 Injection, immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g., liquid), 500 mg
J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg (Only Carimune NF, Panglobulin NF and Gammagard S/D should be billed using this code)
J1568 Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg
J1569 Injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg
J1572 Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g., liquid), 500 mg
J1626 Injection, granisetron hydrochloride, 100 mcg
J2405 Injection, ondansetron hydrochloride, per 1 mg
J2430 Injection, pamidronate disodium, per 30 mg
J3489 Injection, zoledronic acid, 1 mg
J9000 Injection, doxorubicin hydrochloride, 10 mg
J9040 Injection, bleomycin sulfate, 15 units
J9045 Injection, carboplatin, 50 mg
J9060 Injection, cisplatin, powder or solution, per 10 mg
J9130 Dacarbazine, 100 mg
J9181 Injection, etoposide, 10 mg
J9190 Injection, fluorouracil, 500 mg
J9202 Goserelin acetate implant, per 3.6 mg
J9206 Injection, irinotecan, 20 mg
J9217 Leuprolide acetate (for depot suspension), 7.5 mg
J9265 Injection, paclitaxel, 30 mg
J9390 Injection, vinorelbine tartrate, per 10 mg

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