Author: Outpatient Pharmacy Services
Effective with date of service April 1, 2018, the North Carolina Medicaid and N.C. Health Choice (NCHC) programs cover ibalizumab-uiyk injection, for intravenous use (Trogarzo) for use in the Physician’s Drug Program (PDP) when billed with HCPCS code J3590 - Unclassified biologics.
Trogarzo is available as an injection of 200 mg/1.33 mL (150 mg/mL) in a single-dose vial. Its FDA approved indication includes the use, in combination with other antiretrovirals, for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in heavily treatment-experienced adults with multidrug resistant HIV-1 infection failing their current antiretroviral regimen. The recommended dose is a single-loading dose intravenously of 2,000 mg followed by a maintenance dose of 800 mg every two weeks. See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing is B20 - Human immunodeficiency virus (HIV) disease.
- Providers must bill with HCPCS code J3590 - Unclassified biologics.
- One Medicaid and NCHC unit of coverage is 1 mg.
- The maximum reimbursement rate per unit is $6.129.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NCD is 62064-0122-02.
- 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 the North Carolina 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 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 Physician's Drug Program is available on Medicaid’s PDP web page.
CSRA 1-800-688-6696