Eptinezumab-jjmr Injection, for Intravenous Use (Vyepti™) HCPCS Code J3590: Billing Guidelines

Tuesday, May 19, 2020

Effective with date of service April 6, 2020, the NC Medicaid and NC Health Choice programs cover eptinezumab-jjmr injection, for intravenous use (Vyepti™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.

Vyepti™ is available as 100 mg/mL solution in a single-dose vial.  It is indicated for the preventive treatment of migraine in adults.

Recommended Dose (see full prescribing information for further detail): 

  • 100 mg as an intravenous infusion over approximately 30 minutes every 3 months
  • Some patients may benefit from a dosage of 300 mg

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis codes required for billing are: G43.001 - Migraine without aura, not intractable, with status migrainosus; G43.011 - Migraine without aura, intractable, with status migrainosus; G43.019 - Migraine without aura, intractable, without status migrainosus; G43.101 - Migraine with aura, not intractable, with status migrainosus; G43.109 - Migraine with aura, not intractable, without status migrainosus; G43.111 - Migraine with aura, intractable, with status migrainosus; G43.119 - Migraine with aura, intractable, without status migrainosus; G43.401 - Hemiplegic migraine, not intractable, with status migrainosus; G43.409 - Hemiplegic migraine, not intractable, without status migrainosus; G43.411 - Hemiplegic migraine, intractable, with status migrainosus; G43.419 - Hemiplegic migraine, intractable, without status migrainosus; G43.501 - Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus; G43.509 - Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus; G43.511 - Persistent migraine aura without cerebral infarction, intractable, with status migrainosus; G43.519 - Persistent migraine aura without cerebral infarction, intractable, without status migrainosus; G43.601 - Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus; G43.609 - Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus; G43.611 - Persistent migraine aura with cerebral infarction, intractable, with status migrainosus; G43.619 - Persistent migraine aura with cerebral infarction, intractable, without status migrainosus; G43.701 - Chronic migraine without aura, not intractable, with status migrainosus; G43.709 - Chronic migraine without aura, not intractable, without status migrainosus; G43.711 - Chronic migraine without aura, intractable, with status migrainosus; G43.719 - Chronic migraine without aura, intractable, without status migrainosus; G43.801 - Other migraine, not intractable, with status migrainosus; G43.809 - Other migraine, not intractable, without status migrainosus; G43.811 - Other migraine, intractable, with status migrainosus; G43.819 - Other migraine, intractable, without status migrainosus; G43.821 - Menstrual migraine, not intractable, with status migrainosus; G43.829 - Menstrual migraine, not intractable, without status migrainosus; G43.831 - Menstrual migraine, intractable, with status migrainosus; G43.839 - Menstrual migraine, intractable, without status migrainosus; G43.901 - Migraine, unspecified, not intractable, with status migrainosus; G43.909 - Migraine, unspecified, not intractable, without status migrainosus; G43.911 - Migraine, unspecified, intractable, with status migrainosus; G43.919 - Migraine, unspecified, intractable, without status migrainosus; G43.B0 - Ophthalmoplegic migraine, not intractable; G43.B1 - Ophthalmoplegic migraine, intractable

  • 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: $16.15
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 67386-0130-51
  • 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 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