Author: GDIT, (800) 688-6696
Effective with date of service June 11, 2019, the North Carolina Medicaid and NC Health Choice programs cover polatuzumab vedotin-piiq for injection, for intravenous use (Polivy) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Strength/package size(s): For injection: 140 mg of polatuzumab vedotin-piiq as a lyophilized powder in a single-dose vial.
Indicated in combination with bendamustine and a rituximab product for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified, after at least two prior therapies.
Recommended Dose: 1.8 mg/kg as an intravenous infusion over 90 minutes every 21 days for six cycles in combination with bendamustine and a rituximab product. Subsequent infusions may be administered over 30 minutes if the previous infusion is tolerated.
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: C83.30 - Diffuse large B-cell lymphoma, unspecified site; C83.31 - Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck; C83.32 - Diffuse large B-cell lymphoma, intrathoracic lymph nodes; C83.33 - Diffuse large B-cell lymphoma, intra-abdominal lymph nodes; C83.34 - Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb; C83.35 - Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb; C83.36 - Diffuse large B-cell lymphoma, intrapelvic lymph nodes; C83.37 - Diffuse large B-cell lymphoma, spleen; C83.38 - Diffuse large B-cell lymphoma, lymph nodes of multiple sites; C83.39 - Diffuse large B-cell lymphoma, extranodal and solid organ sites
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $115.71
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDC is: 50242-0105-01
- 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.