Author: GDIT, (800) 688-6696
Effective with date of service Oct. 3, 2018, North Carolina Medicaid and NC Health Choice programs cover mogamulizumab-kpkc injection, for intravenous use (Poteligeo), for use in the Physician Administered Drug Program when billed with HCPCS code J9999 - Not Otherwise Classified, Antineoplastic Drugs.
Poteligeo is available as a single-dose vial containing 20 mg/5 mL.
It is indicated for the treatment of adult patients with relapsed or refractory mycosis fungoides or Sézary syndrome after at least one prior systemic therapy.
Recommended Dose
1 mg/kg as an intravenous infusion over at least 60 minutes on days 1, 8, 15 and 22 of the first 28-day cycle and on days 1 and 15 of each subsequent cycle until disease progression or unacceptable toxicity.
See full prescribing information for further detail.
• Providers must bill with HCPCS code: J9999 - Not Otherwise Classified, Antineoplastic Drugs
• One Medicaid and NC Health Choice unit of coverage is 1 mg
• Maximum reimbursement rate per unit is $204.66
• Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is 42747-0761-01
• 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 PADP, refer to the PADP Clinical Coverage Policy No. 1B, Attachment A, H.7 on the NC Medicaid website.
• Providers shall bill their usual and customary charge for non-340B drugs.
• PDP reimburses for drugs billed for Medicaid and NC Health Choice beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.
• The fee schedule for the Physician Administered Drug Program is available on Medicaid website PADP page.
Information is current as of Oct. 24, 2018, and is not a substitute for professional judgment. For full prescribing information, please refer to current package insert or other appropriate sources prior to making clinical judgments.