Author: CSRA
Effective with date of service Nov. 27, 2017, the North Carolina Medicaid and NC Health Choice (NCHC) Program covers emicizumab-kxwh injection (Hemlibra), for subcutaneous use in the Physician’s Drug Program (PDP) when billed with HCPCS code J3590 - Unclassified biologics. Hemlibra is available as a single-dose vial for injection: 30 mg/mL, 60 mg/0.4 mL, 105 mg/0.7 mL, 150 mg/mL.
Hemlibra is indicated for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients with hemophilia A (congenital factor VIII deficiency) with factor VIII inhibitors. The recommended dose is 3 mg/kg by subcutaneous injection once weekly for the first four weeks, followed by 1.5 mg/kg once weekly.
See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing is D66 - Hereditary factor VIII deficiency.
- Providers must bill with HCPCS code J3590 - Unclassified biologics.
- One Medicaid unit of coverage is 1 mg. NCHC bills according to Medicaid units.
- The maximum reimbursement rate per unit is $107.14.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are: 50242-0920-01, 50242-0921-01, 50242-0922-01 and 50242-0923-01.
- 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 Medicaid’s 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 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 Medicaid’s PDP web page.
CSRA 1-800-688-6696