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  • EmblemHealth Specialty Pharmacy Program > Reimbursement


    GHI PPO/EPO Reimbursement Methodology for Radiopharmaceuticals

    Beginning June 1, 2017, invoices are no longer required for GHI PPO/EPO claims to be paid when billing radiopharmaceutical codes.

    With respect to the radiopharmaceutical codes below, defined by Health Common Procedure Coding System (HCPCS), EmblemHealth will pay health care professionals the Average Sales Price (ASP) plus 15%. If ASP is not available, the reimbursement rate is Average Wholesale Pricing (AWP) minus 15%.

    • A9500-A9700
    • A4641-A4647
    • Q9949-Q9969

    Reimbursement Methodology for Injectables and In-Office Medications

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

    • 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 Sales 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

    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, 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

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    Glossary terms found on this page:

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The government agency responsible for administering the Medicare and Medicaid programs.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.

    A drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug.

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

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