New Reimbursement Methodology for Injectables and In-Office Medications

Date Issued: 10/14/2016

EmblemHealth periodically reviews and adjusts reimbursement levels to reflect changes in market prices for acquiring and administering drugs. Effective February 1, 2017, we are implementing the following reimbursement methodology for our Injectables and Other In-Office Medication Fee Schedule.

  • Maximum Allowable Cost (MAC): Utilized for select therapeutic categories where a clinically equivalent, lower-cost alternative is available. Pricing is at the maximum allowable cost giving increased reimbursement over current Average Sale Price (ASP) rates, with margins comparable to higher cost agents within the same therapeutic class.
  • High-Cost Maximum Allowable Cost (High-Cost MAC): Utilized for select-branded, single-source drugs with no lower-cost alternative that provides fair and typical margin. 
  • Average Sales Price (ASP) plus 15%: Utilized for multisource or generic drugs with an ASP available. 
  • Average Sales Price (ASP) plus 10%: Utilized for branded or single-source drugs with an ASP available.
  • Average Sales Price (ASP) plus 8%: Utilized for preferred hyaluronic acid product.
  • Average Sales Price (ASP) plus 6%: Utilized for branded or single-source drugs not included in the ASP plus 10% category.  
  • Average Wholesale Price (AWP) minus 15%: Utilized for drugs without an available ASP except for vaccines, implants and contraceptives.
  • Average Wholesale Price (AWP) minus 10%: Utilized for all vaccines.
  • Average Wholesale Price (AWP): Utilized for all implants and contraceptives.

Injectables and Other In-Office Medication Fee Schedule

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

Code Code Description
90283 Immune Globulin (IgIV), human, for intravenous use (Code Price is per 500 mg) (Use 90283 for CPT billing requirements ONLY - see also J1459, J1557, J1561, J1566, J1568, J1569, J1572 and J1599 for non-CPT billing)
J0640 Injection, leucovorin calcium, per 50 mg
J0641 Injection, levoleucovorin calcium, 0.5 mg
J1442 Injection, filgrastim (G-CSF), 1 microgram
J1447 Injection, tbo-filgrastim, 1 microgram
J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g liquid), 500 mg
J1556 Injection, immune globulin (Bivigam), 500 mg (For billing prior to 1/1/14 see C9130 or J1599)
J1557 Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg (For billing prior to 1/1/12 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
J2469 Injection, palonosetron HCl, 25 mcg
J3489 Injection, zoledronic acid, 1 mg
J9171 Injection, docetaxel, 1 mg
J9217 Leuprolide acetate (for depot suspension), 7.5 mg
J9267 Injection, paclitaxel, 1 mg
Q5101 Injection, filgrastim, (G-CSF), biosimilar, 1 microgram (Code became effective for Medicare billing 3/6/15)

HCPCS for injectables and other in-office medications priced at High Cost MAC are listed in the table below.

Code Code Description
J0202 Injection, alemtuzumab, 1 mg
J1300 Injection, eculizumab, 10 mg
J2860 Injection, siltuximab, 10 mg (Code re-used by CMS effective 1/1/16) (For billing prior to 1/1/16 use C9455 or J3590)
J9032 Injection, belinostat, 10 mg (For billing prior to 1/1/16 use C9442 or J9999)
J9039 Injection, blinatumomab, 1 microgram (For billing prior to 1/1/16 use C9449 or J9999)
J9042 Injection, brentuximab vedotin, 1 mg (For billing prior to 1/1/13 use C9287 or J9999)
J9043 Injection, cabazitaxel, 1 mg (For billing prior to 1/1/12 use J9999 or C9276)
J9228 Injection, ipilimumab, 1 mg (For billing prior to 1/1/12 use J9999 or C9284)
J9264 Injection, paclitaxel protein-bound particles, 1 mg
J9271 Injection, pembrolizumab, 1 mg (For billing prior to 1/1/16 use C9027 or J9999)
J9299 Injection, nivolumab, 1 mg (For billing prior to 1/1/16 use C9453 or J9999)
J9306 Injection, pertuzumab, 1 mg (For billing prior to 1/1/14 use C9292 or J9999)
J9308 Injection, ramucirumab, 5 mg (For billing prior to 1/1/16 use C9025 or J9999)
J9315 Injection, romidepsin, 1 mg (For billing prior to 1/1/11 use J9999 or C9265)
J9354 Injection, ado-trastuzumab emtansine, 1 mg (For billing prior to 1/1/14 use C9131 or J9999)
Q2043 Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Code Price is per 250 mL)

HCPCS for injectables and other in-office medications priced at ASP plus 10% are listed in the table below.

Code Code Description
J0129 Injection, abatacept, 10 mg (Code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug self administered)
J0135 Injection, adalimumab, 20 mg
J0180 Injection, agalsidase beta, 1 mg
J0220 Injection, alglucosidase alfa, 10 mg, not otherwise specified
J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg (For billing prior to 1/1/12 use J3590 or C9277)
J0490 Injection, belimumab, 10 mg
J0587 Injection, rimabotulinumtoxinB,100 units
J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units (For billing prior to 1/1/11 use J3590 or C9269)
J0598 Injection, C1 esterase inhibitor (human), Cinryze, 10 units
J0717 Injection, certolizumab pegol, 1 mg (Code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg (For billing prior to 1/1/11 use J3590 or C9266)
J0875 Injection, dalbavancin, 5 mg (For billing prior to 1/1/16 use C9443 or J3490)
J1290 Injection, ecallantide, 1 mg (For billing prior to 1/1/11 use J3590 or C9263)
J1438 Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician; not for use when drug is self-administered)
J1602 Injection, golimumab, 1 mg, for intravenous use (For billing prior to 1/1/14 use C9399 or J3590)
J1745 Injection, infliximab, 10 mg
J1786 Injection, imiglucerase, 10 units
J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg
J2278 Injection, ziconotide, 1 microgram
J2323 Injection, natalizumab, 1 mg
J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg
J2357 Injection, omalizumab, 5 mg
J2407 Injection, oritavancin, 10 mg (For billing prior to 1/1/16 use C9444 or J3490)
J2507 Injection, pegloticase, 1 mg (For billing prior to 1/1/12 use J3590 or C9281)
J2562 Injection, plerixafor, 1 mg (For billing prior to 1/1/10 use J3490 or C9252)
J2783 Injection, rasburicase, 0.5 mg
J2791 Injection, Rho(D) immune globulin (human), (Rhophylac), intramuscular or intravenous, 100 IU (see also 90384 and 90386 for CPT billing requirements)
J2792 Injection, rho D immune globulin, intravenous, human, solvent detergent, 100 IU (see also 90384 and 90386 for CPT billing requirements)
J2796 Injection, romiplostim, 10 micrograms (For billing prior to 1/1/10 use J3590 or C9245)
J3060 Injection, taliglucerase alfa, 10 units
J3090 Injection, tedizolid phosphate, 1 mg (For billing prior to 1/1/16 use C9446 or J3490)
J3240 Injection,thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial (Code Price is per 1 vial)
J3262 Injection, tocilizumab, 1 mg (For billing prior to 1/1/11 use J3590 or C9264)
J3357 Injection, ustekinumab, 1 mg (For billing prior to 1/1/11 use J3590 or C9261)
J3380 Injection, vedolizumab, 1 mg (For billing prior to 1/1/16 use C9026 or J3590)
J3385 Injection, velaglucerase alfa, 100 units (For billing prior to 1/1/11 use J3490 or C9271)
J3396 Injection, verteporfin, 0.1 mg
J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU VWF:RCO
J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha), per IU
J7186 Injection, antihemophilic factor VIII/Von Willebrand factor complex (human), per factor VIII I.U.
J7187 Injection, Von Willebrand factor complex (Humate-P), per IU, VWF:RCO
J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 microgram
J7190 Factor VIII (antihemophilic factor [human]) per IU
J7192 Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified
J7193 Factor IX (antihemophilic factor, purified, non-recombinant) per IU
J7194 Factor IX, complex, per IU
J7195 Injection factor IX (antihemophilic factor, recombinant) per IU, not otherwise specified
J7205 Injection, factor VIII, Fc fusion protein (recombinant), per IU
J7313 Injection, fluocinolone acetonide intravitreal implant, 0.01 mg (For billing prior to 1/1/16 use C9450 or J3490)
J7316 Injection, ocriplasmin, 0.125 mg (For billing prior to 1/1/14 use C9298 or J3590) (Code re-used by CMS 1/1/14)
J8655 Netupitant 300 mg and palonosetron 0.5 mg (Code Price is per 1 capsule)
J9019 Injection, asparaginase (Erwinaze), 1,000 IU (For billing prior to 1/1/13 use C9289 or J9999)
J9027 Injection, clofarabine, 1 mg
J9033 Injection, bendamustine HCl, 1 mg
J9035 Injection, bevacizumab, 10 mg
J9041 Injection, bortezomib, 0.1 mg
J9047 Injection, carfilzomib, 1 mg (For billing prior to 1/1/14 use C9295 or J9999)
J9055 Injection, cetuximab, 10 mg
J9179 Injection, eribulin mesylate, 0.1 mg (For billing prior to 1/1/12 use J9999 or C9280)
J9207 Injection, ixabepilone, 1 mg
J9266 Injection, pegaspargase, per single dose vial
J9302 Injection, ofatumumab, 10 mg (For billing prior to 1/1/11 use J9999 or C9260)
J9303 Injection, panitumumab, 10 mg
J9305 Injection, pemetrexed, 10 mg
J9307 Injection, pralatrexate, 1 mg (For billing prior to 1/1/11 use J9999 or C9259)
J9310 Injection, rituximab, 100 mg
J9330 Injection, temsirolimus, 1 mg
J9355 Injection, trastuzumab, 10 mg
J9357 Injection, valrubicin, intravesical, 200 mg
J9395 Injection, fulvestrant, 25 mg
J9400 Injection, ziv-aflibercept, 1 mg (For billing prior to 1/1/14 use C9296 or J9999)
Q2049 Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg

HCPCS for injectables and other in-office medications priced at ASP plus 8% are listed in the table below.

Code Code Description
J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, Per dose

HCPCS for injectables and other in-office medications priced at ASP+6% are listed in the table below.

Code Code Description
J0178 Injection, aflibercept, 1 mg
J0585 Injection, onabotulinumtoxinA, 1 unit
J0897 Injection, denosumab, 1 mg (For billing prior to 1/1/12 use J3590 or C9272)
J2503 Injection, pegaptanib sodium, 0.3 mg
J2505 Injection, pegfilgrastim, 6 mg
J2778 Injection, ranibizumab, 0.1 mg
J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose (Hyalgan dose is 20 mg/2 mL and Supartz dose is 25 mg/2.5 mL) (Note: Total dose regimen = 3 - 5 injections)
J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (20 mg/2 mL) (Note: Total dose regimen = 3 injections)
J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (30 mg/2 mL) (Note: Total dose regimen = 3 - 4 injections)
J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg (For billing prior to 1/1/10 see J7322 for Synvisc and J3490 for Synvisc-One)
J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose (For billing prior to 1/1/15 use C9399 or J3490) (Dose 88 mg/4 mL) (Note: Total dose regimen = 1 dose)
J7328 Hyaluronan or derivative, Gel-Syn, for intra-articular injection, 0.1 mg
Q9980 Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1 mg

HCPCS for injectables and other in-office medications priced at AWP are listed in the table below.

Code Code Description
J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration
J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration
J7300 Intrauterine copper contraceptive
J7301 Levonorgestrel-releasing intrauterine contraceptive system,13.5 mg
J7307 Etonogestrel (contraceptive) implant system, including implant and supplies (Code Price is per 1 implant system)
J7311 Fluocinolone acetonide, intravitreal implant
J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg (For billing prior to 1/1/11 use J3490 or C9256)
J7330 Autologous cultured chondrocytes, implant
J9225 Histrelin implant (Vantas), 50 mg
J9226 Histrelin implant (Supprelin LA), 50 mg
S1090 Mometasone furoate sinus implant, 370 micrograms - see also C2625 or J3490