Author: CSRA 1-800-688-6696
Effective with date of service Oct. 15, 2017, the NC Medicaid Program covers triamcinolone acetonide extended-release injectable suspension, for intra-articular use (Zilretta) for use in the Physician’s Drug Program (PDP) when billed with HCPCS code J3490 - Unclassified drugs. Zilretta is currently commercially available as a single-dose kit containing one vial of Zilretta microsphere powder (32 mg of triamcinolone acetonide), one vial of 5 mL diluent, and one sterile vial adapter.
Zilretta is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. Zilretta is not intended for repeat administration. The recommended dose of Zilretta is 32 mg administered as a single intra-articular injection in the knee. See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing is/are:
- M17.0 - Bilateral primary osteoarthritis of knee;
- M17.11 - Unilateral primary osteoarthritis of knee, right knee;
- M17.12 - Unilateral primary osteoarthritis of knee, left knee;
- M17.2 - Bilateral post-traumatic osteoarthritis of knee;
- M17.31 - Unilateral post-traumatic osteoarthritis, right knee;
- M17.32 - Unilateral post-traumatic osteoarthritis, left knee;
- M17.4 - Other bilateral secondary osteoarthritis of knee;
- M17.5 - Other unilateral secondary osteoarthritis of knee.
- Providers must bill with HCPCS code: J3490 - Unclassified drugs.
- One Medicaid unit of coverage is 1 kit.
- The maximum reimbursement rate per unit is $615.60.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is/are: 70801-0003-01.
- The NDC units should be reported as “UN1.”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
- For additional information regarding NDC claim requirements related to the PDP, refer to the PDP Clinical Coverage Policy No. 1B, Attachment A, H.7 on DMA's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PDP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.
- The fee schedule for the Physician's Drug Program is available on DMA’s PDP web page.