Author: GDIT, (800) 688-6696
Effective with date of service Oct. 22, 2018, the NC Medicaid and Health Choice (NCHC) programs cover moxetumomab pasudotox-tdfk for injection, for intravenous use (Lumoxiti™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not Otherwise Classified, antineoplastic drugs.
Lumoxiti is available for injection as 1 mg lyophilized cake or powder in a single-dose vial for reconstitution and further dilution.
It is indicated for the treatment of adult patients with relapsed or refractory hairy cell leukemia (HCL) who received at least two prior systemic therapies, including treatment with a purine nucleoside analog (PNA). Lumoxiti is not recommended in patients with severe renal impairment (CrCl ≤ 29 mL/min).
Recommended Dose: 0.04 mg/kg as an intravenous infusion over 30 minutes on days one, three and five of each 28-day cycle.
See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing is/are: C91.40 - Hairy cell leukemia not having achieved remission or C91.42 - Hairy cell leukemia, in relapse in combination with Z92.21 - Personal history of antineoplastic chemotherapy
- Providers must bill with HCPCS code: J9999 - Not Otherwise Classified, Antineoplastic Drugs
- One Medicaid and NCHC unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $2,250.00
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is/are: 00310-4700-01
- 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 Clinical Coverage Policy No. 1B, Attachment A, H.7.
- 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.
*Information current as of Nov. 28, 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.