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Q1 2022 Update to Injectable Medication/Specialty Pharmacy Fee Schedule

Horizon will update our fee schedule for injectable medications on February 1, 2022. Effective February 1, 2022, the fees for the injectable medications listed in the table below will decrease as noted.

We update our injectable medication fee schedule each quarter. The majority of changes made each quarter reflect industry-wide changes to the Average Sales Price (ASP) or the Average Wholesale Price (AWP) of an injectable medication. The changes noted in the table below identify decreases in injectable medication fees that do not reflect industry-wide changes in the ASP or AWP.

Code Description Final Rate Prior Rate Source
90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use $53.27 $64.58 AWP-15%
J0795 Injection, corticorelin ovine triflutate, 1 microgram $9.31 $10.49 AWP-15%
J1557 Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg $52.65 $54.04  
J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg $71.05 $71.48  
J1569 Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg $48.27 $51.76  
J2405 Injection, ondansetron hydrochloride, per 1 mg $0.14 $0.20  
J2430 Injection, pamidronate disodium, per 30 mg $35.84 $47.89  
J2469 Injection, palonosetron hcl, 25 mcg $0.93 $1.83  
J9043 Injection, cabazitaxel, 1 mg $186.47 $187.63  
J9171 Injection, docetaxel, 1 mg $0.49 $0.55  
J9315 Injection, romidepsin, 1 mg $326.26 $349.55 AWP-15%
Q5101 Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram $0.42 $0.47  

Please note that the specialty drugs represented by codes 90653, J0795 and J9315 have moved from ASP to AWP pricing.

Claims processed on and after February 1, 2022 that include these injectable medications will be reimbursed based on our revised fee schedule information. Horizon BCBSNJ reserves the right to adjust claims for services provided on and after February 1, 2022 that are not reimbursed according to this updated information.

ASP information for Medicare Part B drugs is posted by the Centers for Medicare & Medicaid Services on the first day of the quarter. AWP information, based on data obtained from manufacturers, distributors and other suppliers, is available from a variety of commercial sources

Fee Schedule Inquiry Tool

The complete injectable medication fee schedule information is available on our Fee Schedule Inquiry tool. Changes to our injectable medication fee schedule information are accessible on and after the effective date of a quarterly update.

To access, log into NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:

  • Mouse over Claim Management
  • Select Fee Request Inquiry

To view allowances for specific injectable medications or other services:

  • Select your Billing Provider number, County and Specialty
  • Enter the desired CPT® and/or HCPCS codes
  • Select Submit

CPT® is a registered mark of the American Medical Association.

Published on: November 1, 2021, 12:31 p.m. ET
Last updated on: October 29, 2021, 03:56 a.m. ET