Author: GDIT, (800) 688-6696
Effective with date of service 3/8/2019, the North Carolina Medicaid and NC Health Choice programs cover esketamine nasal spray (Spravato™) for use in the Physician Administered Drug Program when billed with HCPCS code J3490 - Unclassified drugs.
Spravato is available as a nasal spray: 28 mg of esketamine per device. Each nasal spray device delivers two sprays containing a total of 28 mg of esketamine. Spravato is indicated, in conjunction with an oral antidepressant, for the treatment of treatment-resistant depression (TRD) in adults.
Recommended Dose:
Induction Phase (Weeks 1 to 4): Administer twice weekly. Day 1: 56 mg, subsequent doses: 56 mg or 84 mg.
Maintenance Phase (Weeks 5 to 8): Administer 56 mg or 84 mg once weekly.
Maintenance Phase (Week 9 and after): Administer 56 mg or 84 mg once weekly or every 2 weeks.
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are: F32.1 - Major depressive disorder, single episode, moderate; F32.2 - Major depressive disorder, single episode, severe without psychotic features; F32.4 - Major depressive disorder, single episode, in partial remission; F33.1 - Major depressive disorder, recurrent, moderate; F33.2 - Major depressive disorder, recurrent severe without psychotic features; F33.41 - Major depressive disorder, recurrent, in partial remission;
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 device (28 mg)
- The maximum reimbursement rate per unit is: $318.60
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is/are: 50458-0028-00, 50458-0028-02, 50458-0028-03
- 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 DHB's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PADP 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 DHB's PADP web page.