Author: GDIT, (800) 688-6696
Effective with date of service Jan. 28, 2020, the Medicaid and NC Health Choice programs cover teprotumumab-trbw for injection, for intravenous use (Tepezza™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size(s): For Injection: 500 mg lyophilized powder in a single-dose vial for reconstitution
Indicated for the treatment of Thyroid Eye Disease.
Recommended Dose:
- First infusion: 10 mg/kg
- Additional 7 infusions: 20 mg/kg every 3 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: E05.00 - Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm; E05.01 - Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm; E05.10 - Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm; E05.11 - Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm; E05.20 - Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm; E05.21 - Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm; E05.30 - Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm; E05.31 - Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm; E05.40 - Thyrotoxicosis factitia without thyrotoxic crisis or storm; E05.41 - Thyrotoxicosis factitia with thyrotoxic crisis or storm; E05.80 - Other thyrotoxicosis without thyrotoxic crisis or storm; E05.81 - Other thyrotoxicosis with thyrotoxic crisis or storm; E05.90 - Thyrotoxicosis, unspecified without thyrotoxic crisis or storm; E05.91 - Thyrotoxicosis, unspecified with thyrotoxic crisis or storm.
- 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: $32.18.
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 75987-0130-15.
- 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 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.