Author: GDIT, (800) 688-6696
Effective with date of service Nov. 19, 2018, the NC Medicaid and Health Choice (NCHC) programs cover risperidone for extended-release injectable suspension, for subcutaneous use (Perseris™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Perseris is available as a 90 mg single-dose kit and a 120 mg single-dose kit. Perseris is indicated for the treatment of schizophrenia in adults.
Recommended Dose: For adult patients who have never taken risperidone, establish tolerability with oral risperidone prior to starting. Then, initiate Perseris at a dose of 90 mg or 120 mg once monthly by abdominal subcutaneous injection. See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are:
- F20.0 - Paranoid schizophrenia
- F20.1 - Disorganized schizophrenia
- F20.2 - Catatonic schizophrenia
- F20.3 - Undifferentiated schizophrenia
- F20.5 - Residual schizophrenia
- F20.89 - Other schizophrenia
- F20.9 - Schizophrenia, unspecified
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NCHC unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $20.52
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is/are: 12496-0090-01, 12496-0120-01
- 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.