Elapegademase-lvlr injection, for intramuscular use (Revcovi™) HCPCS code J3590: Billing Guidelines

Effective with date of service Nov. 28, 2018, the NC Medicaid and Health Choice (NCHC) programs cover elapegademase-lvlr injection, for intramuscular use (Revcovi™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.

Revcoci is available as 2.4 mg/1.5 mL (1.6 mg/mL) in a single-dose vial. It is indicated for the treatment of adenosine deaminase severe combined immune deficiency (ADA-SCID) in pediatric and adult patients.

Recommended Dose: 
Patients transitioning from Adagen to Revcovi:

• If a patient’s weekly Adagen dose is unknown, or a patient’s weekly Adagen dose is at or lower than 30 U/kg, the recommended minimum starting dose is 0.2 mg/kg, intramuscularly, once a week.
• If a patient’s weekly Adagen dose is above 30 U/kg, an equivalent weekly Revcovi dose (mg/kg) should be calculated using the following conversion formula: Adagen dose in U/kg divided by 150.

Adagen-naïve patients:
The starting dose is 0.4 mg/kg weekly based on ideal body weight, divided into two doses (0.2 mg/kg twice a week), intramuscularly for a minimum of 12 to 24 weeks until immune reconstitution is achieved. 

See full prescribing information for further detail.

For Medicaid and NCHC Billing

• The ICD-10-CM diagnosis code(s) required for billing is/are:  D81.3 - Adenosine deaminase [ADA] deficiency
• 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: $4,435.20
• Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is/are: 57665-0002-01
• 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 PADP, refer to the PADP, Attachment A, H.7 on NC Medicaid's website.
• Providers shall bill their usual and customary charge for non-340B drugs.
• PADP reimburses for drugs billed for Medicaid and NCHC 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 PADP is available on NC Medicaid's PADP web page.