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FDA Approval: 9/14/18 Migraine is a debilitating disorder that affects millions of people in the United States. Migraine can affect individuals in a way that deprives them of their normal, daily activities, and often results in pain, physical impairment, lost productivity, and increased financial cost. Fremanezumab-vfrm, developed by Teva Pharmaceutical Industries Ltd., is a fully […]

Consider that the average cost for a medically covered drug is +$200 (Client Claims data). Errors associated with the processing of these claims have significant implications. Data quality must be monitored and updated into processes and systems to avoid these risks. This is compounded by the challenge of infrequent updates to the pricing methodology or […]

FDA Approval: 9/13/2018 Hairy cell leukemia (HCL) is a rare, slow-growing cancer of the blood in which the bone marrow produces too many abnormal B cells or lymphocytes. This compromises the bone marrow’s ability to produce healthy blood cells and platelets. Patients with HCL may experience enlargement of the spleen, increased susceptibility to life-threatening conditions […]

Appropriate reimbursement for drugs covered by the medical benefit requires more data and structure than most medical claims or billing systems were originally intended to process. This applies even more so when the systems are proprietary. The tendency to solve this issue has been to apply headcount (ex- case workers & analysts), continually enhance existing […]

Medically covered drug pricing is highly sensitive, and changes occur frequently. The more variability in a system, the greater the chance for errors and inefficiencies. Regarding price methodologies, most reimbursements are based on CMS’ Average Sales Price (ASP) and/or Manufacturers’ Average Wholesale Price (AWP). This should be straightforward. However, payments, driven by a coding process […]

Each year there are dozens of new drugs (56 in 2018) and new CMS HCPCS assignments (38 in January 2018), as well as hundreds of new indications approved. This is in addition to the ongoing updates in coding assignments, pricing, generic entries and more. Consider that the average cost for a medically covered drug is […]

NDC mandates have been in place for Medicaid covered lives for over a decade. In recent years, this requirement has been expanded to account for additional lines of business. This shift creates a larger member population which in turn creates new claim volume. The addition of the volume mixed with the requirement for electronic claim […]

INSIDE THIS ISSUE Code Updates: Large Price Changes New Q-Codes Effective October 1, 2018 New C-Codes for Hospital OPPS use Effective October 1, 2018 CMS News: Medicare Influenza Vaccine Pricing 2018-2019 Season NEW Influenza CPT® Code 90689 Effective January 1, 2019 Medicare Coverage Indicator Change for Q9994 Drug Reimbursement Code Price Updates Drugs/Devices: New Clinical […]

RJ identified a total of seven new FDA drug approvals specific to the specialty market in August 2018, and six supplemental drug approvals. The FDA had assigned four new products for review. Review the August 2018 RJ Health monthly specialty FDA actions newsletter below for more information. Drugs included in this review are generally regarded […]

Familial amyloid polyneuropathy (FAP, also called transthyretin amyloidosis) is a hereditary neurodegenerative disease that is characterized by the accumulation and deposition of the transthyretin protein (TTR) in the tissues and peripheral nervous system, and often causes pain, muscle weakness, and autonomic dysfunction. Eventually, the disease progresses into a sensory and motor polyneuropathy. Currently, the mainstay […]