Effective with date of service June 19, 2020, the Medicaid and NC Health Choice programs cover lurbinectedin for injection, for intravenous use (Zepzelca™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Strength/Package Size: For injection: 4 mg lyophilized powder in a single-dose vial
Indicated for the treatment of adult patients with metastatic small cell lung cancer (SCLC) with disease progression on or after platinum-based chemotherapy.
Recommended Dose: 3.2 mg/m2 every 21 days. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
|
C33 |
Malignant neoplasm of trachea |
|
C34.00 |
Malignant neoplasm of unspecified main bronchus |
|
C34.01 |
Malignant neoplasm of right main bronchus |
|
C34.02 |
Malignant neoplasm of left main bronchus |
|
C34.10 |
Malignant neoplasm of upper lobe, unspecified bronchus or lung |
|
C34.11 |
Malignant neoplasm of upper lobe, right bronchus or lung |
|
C34.12 |
Malignant neoplasm of upper lobe, left bronchus or lung |
|
C34.2 |
Malignant neoplasm of middle lobe, bronchus or lung |
|
C34.30 |
Malignant neoplasm of lower lobe, unspecified bronchus or lung |
|
C34.31 |
Malignant neoplasm of lower lobe, right bronchus or lung |
|
C34.32 |
Malignant neoplasm of lower lobe, left bronchus or lung |
|
C34.80 |
Malignant neoplasm of overlapping sites of unspecified bronchus and lung |
|
C34.81 |
Malignant neoplasm of overlapping sites of right bronchus and lung |
|
C34.82 |
Malignant neoplasm of overlapping sites of left bronchus and lung |
|
C34.90 |
Malignant neoplasm of unspecified part of bronchus or lung |
|
C34.91 |
Malignant neoplasm of unspecified part of right bronchus or lung |
|
C34.92 |
Malignant neoplasm of unspecified part of left bronchus or lung |
- 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: $1,790.91
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 68727-0712-01
- 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 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