Effective with date of service Feb. 19, 2020, the Medicaid and NC Health Choice programs cover cetirizine hydrochloride injection, for intravenous use (Quzyttir™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Size: Injection: 10 mg/mL cetirizine hydrochloride
Indicated for the treatment of acute urticaria in adults and children 6 months of age and older. Quzyttir™ is not recommended in pediatric patients less than 6 years of age with impaired renal or hepatic function.
Recommended Dose (see full prescribing information for details):
- Adults and adolescents ≥ 12 years of age and older: 10 mg
- Children 6 to 11 years: 5 mg or 10 mg
- Children 6 months to 5 years: 2.5 mg
Recommended dosage regimen is once every 24 hours as needed for acute urticaria.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing is/are: L50.0 - Allergic urticaria; L50.1 - Idiopathic urticaria; L50.2 - Urticaria due to cold and heat; L50.3 - Dermatographic urticaria; L50.4 - Vibratory urticaria; L50.5 - Cholinergic urticaria; L50.6 - Contact urticaria; L50.8 - Other urticaria; L50.9 - Urticaria, unspecified
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $32.40
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 70720-0100-01, 70720-0100-25
- 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.
Contact
NCTracks Contact Center: 800-688-6696