Author: CSRA
Effective with date of service, June 1, 2016, the North Carolina Medicaid and N.C. Health Choice (NCHC) programs cover NETSPOT for use in the Physician’s Drug Program (PDP) when billed with HCPCS code A4641, radiopharmaceutical, diagnostic, not otherwise classified. NETSPOT is available in a single-dose kit containing a reaction vial with lyophilized powder (40 mcg of dotatate) and buffer vial (1 mL of reaction buffer solution).
NETSPOT, after radiolabeling with Ga 68, is a radioactive diagnostic agent indicated for use with positron emission tomography (PET) for localization of somatostatin receptor positive neuroendocrine tumors (NETs) in adults and pediatric patients. NETSPOT is administered with a recommended dose of 2MBq/kg of body weight (0.054 mCi/kg) up to 200 MBq (5.4 mCi) administered as an intravenous bolus injection.
Medicaid and NCHC Billing
- Providers must bill the product with HCPCS code A4641- radiopharmaceutical, diagnostic, not otherwise classified.
- Providers must indicate the number of HCPCS units (assumption: 1 unit = 1 study dose).
- One Medicaid unit of coverage is one study dose. NCHC bills according to Medicaid units.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is 69488-0001-40.
- 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 Clinical Coverage Policy No. 1B, Physician Drug Program, Attachment A, H.7 on the Medicaid website.
- Providers shall bill their usual and customary charge for non-340-B drugs.
- PDP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340-B participating providers who have registered with the registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340-B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340-B purchasing agreement by appending the “UD” modifier on the drug detail.
- The fee schedule for the PDP is available on the North Carolina Medicaid PDP web page
CSRA, 1-800-688-6696