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.
||Injection, leucovorin calcium, per 50 mg|
||Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg|
||Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg (For billing prior to January 1, 2012, use 90283, J1599 or C9270)|
||Injection, immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g., liquid), 500 mg|
||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)|
||Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg|
||Injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg|
||Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g., liquid), 500 mg|
||Injection, granisetron hydrochloride, 100 mcg|
||Injection, ondansetron hydrochloride, per 1 mg|
||Injection, pamidronate disodium, per 30 mg|
||Injection, zoledronic acid, 1 mg|
||Injection, doxorubicin hydrochloride, 10 mg|
||Injection, bleomycin sulfate, 15 units|
||Injection, carboplatin, 50 mg|
||Injection, cisplatin, powder or solution, per 10 mg|
||Dacarbazine, 100 mg|
||Injection, etoposide, 10 mg|
||Injection, fluorouracil, 500 mg|
||Goserelin acetate implant, per 3.6 mg|
||Injection, irinotecan, 20 mg|
||Leuprolide acetate (for depot suspension), 7.5 mg|
||Injection, paclitaxel, 30 mg|
||Injection, vinorelbine tartrate, per 10 mg|
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