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Q1 2023 Update to Injectable Medication/Specialty Pharmacy Fee Schedule

Effective February 1, 2023, the fees for the injectable medications listed in the table below will decrease as noted.

Code Description Final Rate Prior Rate Source
J0178 Injection, aflibercept, 1 mg $926.88 $936.22
J0219 Injection, avalglucosidase alfa-ngpt, 4 mg $69.68 $69.97
J0791 Injection, crizanlizumab-tmca, 5 mg $120.44 $120.85
J1050 Injection, medroxyprogesterone acetate, 1 mg $0.55 $0.62 AWP-15%
J1303 Injection, ravulizumab-cwvz, 10 mg $212.82 $213.52
J1447 Injection, tbo-filgrastim, 1 microgram $0.54 $0.57
J1459 Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg $50.67 $50.92
J1572 Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g., liquid), 500 mg $43.26 $43.96
J1746 Injection, ibalizumab-uiyk, 10 mg $67.34 $67.37
J2778 Injection, ranibizumab, 0.1 mg $273.78 $289.57
J9019 Injection, asparaginase (erwinaze), 1,000 iu $411.15 $443.39 AWP-15%
J9022 Injection, atezolizumab, 10 mg $79.74 $79.94
J9023 Injection, avelumab, 10 mg $84.75 $84.94
J9043 Injection, cabazitaxel, 1 mg $192.75 $193.65
J9071 Injection, cyclophosphamide, (auromedics), 5 mg $2.75 $3.72 ASP+6%
J9171 Injection, docetaxel, 1 mg $0.48 $0.51
J9228 Injection, ipilimumab, 1 mg $158.49 $159.03
J9264 Injection, paclitaxel protein-bound particles, 1 mg $11.79 $14.21
J9267 Injection, paclitaxel, 1 mg $0.14 $0.15
J9269 Injection, tagraxofusp-erzs, 10 micrograms $294.24 $294.81
J9308 Injection, ramucirumab, 5 mg $65.41 $65.46
Q2043 Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion (minimum 50 million cells) $50,981.69 $52,514.99
Q5105 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units $0.85 $0.87
Q5106 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units $8.46 $8.69

We update our injectable medication/Specialty Pharmacy 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 this table identify decreases in injectable medication fees that do not reflect industry-wide changes in the ASP or AWP.

Please note that the specialty drugs represented by codes J1050 and J9091 moved from ASP to AWP pricing and that the specialty drug represented by J9071 moved from AWP to ASP pricing.

Claims processed on and after February 1, 2023 that include these injectable medications will be reimbursed based on our revised fee schedule information. Horizon reserves the right to adjust claims for services provided on and after February 1, 2023 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, 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: October 31, 2022, 11:46 a.m. ET
Last updated on: October 25, 2022, 11:53 a.m. ET