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 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.