Author: CSRA
Effective with date of service Dec. 11, 2107, the North Carolina Medicaid and NC Health Choice (NCHC) programs cover letermovir injection (Prevymis) for intravenous use in the Physician’s Drug Program (PDP) when billed with HCPCS code J3490 - Unclassified drugs.
Prevymis is available as 240 mg/12 mL (20 mg/mL) or 480 mg/24 mL (20 mg/mL) in a single-dose vial. Prevymis is indicated for prophylaxis of cytomegalovirus (CMV) infection and disease in adult CMV-seropositive recipients [R+] of an allogeneic hematopoietic stem cell transplant (HSCT).
The recommended dose of Prevymis is 480 mg administered intravenously once daily through 100 days post-transplant. If Prevymis is co-administered with cyclosporine, the dosage of Prevymis should be decreased to 240 mg once daily. See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing is Z41.8 - Encounter for other procedures for purposes other than remedying health state.
- Providers must bill with HCPCS code J3490 - Unclassified drugs.
- One Medicaid unit of coverage is 1 vial.
- The maximum reimbursement rate per unit is $291.60.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 00006-5003-01 and 00006-5004-01.
- 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