Author: GDIT, (800) 688-6696
Effective with date of service June 20, 2019, the North Carolina Medicaid and NC Health Choice programs cover dexamethasone ophthalmic insert 0.4 mg, for intracanalicular use (Dextenza) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Size(s): Ophthalmic intracanalicular insert containing a 0.4 mg dose of dexamethasone.
Indicated for the treatment of ocular inflammation and pain following ophthalmic surgery.
Recommended Dose: A single Dextenza insert releases a 0.4 mg dose of dexamethasone for up to 30 days following insertion.
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing are: H20.041 - Secondary noninfectious iridocyclitis, right eye; H20.042 - Secondary noninfectious iridocyclitis, left eye; H20.043 - Secondary noninfectious iridocyclitis, bilateral; H20.049 - Secondary noninfectious iridocyclitis, unspecified eye; H57.10 - Ocular pain, unspecified eye; H57.11 - Ocular pain, right eye; H57.12 - Ocular pain, left eye; H57.13 - Ocular pain, bilateral
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 0.4 mg (1 insert)
- The maximum reimbursement rate per unit is: $581.94
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are: 70382-0204-01, 70382-0204-10
- 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.