Author: CSRA
Effective with date of Service Jan. 1, 2018, the North Carolina Medicaid and NC Health Choice (NCHC) programs cover treprostinil injection (Remodulin), for subcutaneous infusion or intravenous infusion in the Physician’s Drug Program (PDP) when billed with HCPCS code J3285 - Injection, treprostinil, 1 mg. Treprostinil is available as 20 mL vials containing 20, 50, 100 or 200 mg of treprostinil (1, 2.5, 5 or 10 mg/mL).
Treprostinil is indicated for treatment of pulmonary arterial hypertension (PAH) (World Health Organization [WHO] Group 1) to diminish symptoms associated with exercise and to diminish the rate of clinical deterioration in patients requiring transition from Flolan. For PAH in patients with New York Heart Association (NYHA) Class II-IV symptoms the initial dose for patients new to prostacyclin infusion therapy is 1.25 ng/kg/min; increases are based on clinical response in increments of 1.25 ng/kg/min per week for the first four weeks of treatment, later 2.5 ng/kg/min per week. For patients transitioning from Flolan, the recommendation is to increase dose gradually as the Flolan dose is decreased, based on constant observation of response.
See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing are:
- I27.0 - Primary pulmonary hypertension
- I27.20 - Pulmonary hypertension, unspecified
- I27.21 - Secondary pulmonary arterial hypertension
- I27.22 - Pulmonary hypertension due to left heart disease
- I27.23 - Pulmonary hypertension due to lung diseases and hypoxia
- I27.24 - Chronic thromboembolic pulmonary hypertension
- I27.29 - Other secondary pulmonary hypertension
- Providers must bill with HCPCS code J3285 - Injection, treprostinil, 1 mg.
- One Medicaid unit of coverage is 1 mg. NCHC bills according to Medicaid units.
- The maximum reimbursement rate per unit is $61.24.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 66302-0101-01, 66302-0102-01, 66302-0105-01 and 66302-0110-01.
- 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