Author: GDIT, (800) 688-6696
Effective with date of service March 7, 2019, the North Carolina Medicaid and NC Health Choice programs cover tagraxofusp-erzs injection, for intravenous use (Elzonris) for use in the Physician Administered Drug Program when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Elzonris is available as a 1,000 mcg in 1 mL in a single-dose vial for injection. It is indicated for the treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adults and in pediatric patients 2 years and older.
Recommended Dose: 12 mcg/kg intravenously over 15 minutes once daily on days 1 to 5 of a 21-day cycle.
See package insert for recommended dose modifications and for CLS management guidelines AND see full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code required for billing is: C86.4 - Blastic NK-cell lymphoma
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mcg
- The maximum reimbursement rate per unit is: $26.38
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is: 72187-0401-01
- 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 1B, 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.