Author: GDIT (800) 688-6696
Effective with date of service Nov. 20, 2019, the NC Medicaid and NC Health Choice programs cover crizanlizumab-tmca injection, for intravenous use (Adakveo) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size(s): Injection: 00 mg/10 mL (10 mg/mL) solution in a single-dose vial.
Indicated to reduce the frequency of vaso-occlusive crises in adults and pediatric patients aged 16 years and older with sickle cell disease.
Recommended Dose: 5 mg/kg by intravenous infusion over a period of 30 minutes on Week 0, Week 2, and every 4 weeks thereafter. 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:
- D57.00 - Hb-SS disease with crisis, unspecified;
- D57.01 - Hb-SS disease with acute chest syndrome;
- D57.02 - Hb-SS disease with splenic sequestration;
- D57.1 - Sickle-cell disease without crisis;
- D57.20 - Sickle-cell/Hb-C disease without crisis;
- D57.211 - Sickle-cell/Hb-C disease with acute chest syndrome;
- D57.212 - Sickle-cell/Hb-C disease with splenic sequestration;
- D57.219 - Sickle-cell/Hb-C disease with crisis, unspecified;
- D57.40 - Sickle-cell thalassemia without crisis;
- D57.411 - Sickle-cell thalassemia with acute chest syndrome;
- D57.412 - Sickle-cell thalassemia with splenic sequestration;
- D57.419 - Sickle-cell thalassemia with crisis, unspecified;
- D57.80 - Other sickle-cell disorders without crisis;
- D57.811 - Other sickle-cell disorders with acute chest syndrome;
- D57.812 - Other sickle-cell disorders with splenic sequestration;
- D57.819 - Other sickle-cell disorders with crisis, unspecified
- Providers must bill with HCPCS code: J3590 - Unclassified biologics
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $25.46
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 00078-0883-61
- The NDC units should be reported as “UN1.”
- For additional information, refer to the January 2012 Medicaid 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 Medicaid'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 PADP is available on Medicaid's PADP web page.