Effective with date of service July 1, 2020, the Medicaid and NC Health Choice programs cover pertuzumab, trastuzumab, and hyaluronidase-zzxf injection, for subcutaneous use (Phesgo™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Strength/Package Sizes:
- 1,200 mg pertuzumab, 600 mg trastuzumab, and 30,000 units hyaluronidase/15 mL (80 mg, 40 mg, and 2,000 units/mL) of solution in a single-dose vial
- 600 mg pertuzumab, 600 mg trastuzumab, and 20,000 units hyaluronidase/10 mL (60 mg, 60 mg, and 2,000 units/mL) of solution in a single-dose vial
Indicated for:
- Use in combination with chemotherapy as:
- neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer
- adjuvant treatment of patients with HER2-positive early breast cancer at high risk of recurrence
- Use in combination with docetaxel for treatment of patients with HER2-positive metastatic breast cancer (MBC) who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease
Recommended Dose (see full prescribing information for further detail):
- The initial dose of Phesgo™ is 1,200 mg pertuzumab, 600 mg trastuzumab, and 30,000 units hyaluronidase administered subcutaneously over approximately 8 minutes, followed every 3 weeks by a dose of 600 mg pertuzumab, 600 mg trastuzumab, and 20,000 units hyaluronidase administered subcutaneously over approximately 5 minutes
- Neoadjuvant: administer Phesgo™ by subcutaneous injection every 3 weeks and chemotherapy by intravenous infusion preoperatively for 3 to 6 cycles
- Adjuvant: administer Phesgo™ by subcutaneous injection every 3 weeks and chemotherapy by intravenous infusion postoperatively for a total of 1 year (up to 18 cycles)
- MBC: administer Phesgo™ by subcutaneous injection and docetaxel by intravenous infusion every 3 weeks
For Medicaid and NC Health Choice Billing
-
The ICD-10-CM diagnosis codes required for billing is/are:
Malignant neoplasm of the female breast: |
|
C50.011 |
Malignant neoplasm of nipple and areola, right female breast |
C50.012 |
Malignant neoplasm of nipple and areola, left female breast |
C50.019 |
Malignant neoplasm of nipple and areola, unspecified female breast |
C50.111 |
Malignant neoplasm of central portion of right female breast |
C50.112 |
Malignant neoplasm of central portion of left female breast |
C50.119 |
Malignant neoplasm of central portion of unspecified female breast |
C50.211 |
Malignant neoplasm of upper-inner quadrant of right female breast |
C50.212 |
Malignant neoplasm of upper-inner quadrant of left female breast |
C50.219 |
Malignant neoplasm of upper-inner quadrant of unspecified female breast |
C50.311 |
Malignant neoplasm of lower-inner quadrant of right female breast |
C50.312 |
Malignant neoplasm of lower-inner quadrant of left female breast |
C50.319 |
Malignant neoplasm of lower-inner quadrant of unspecified female breast |
C50.411 |
Malignant neoplasm of upper-outer quadrant of right female breast |
C50.412 |
Malignant neoplasm of upper-outer quadrant of left female breast |
C50.419 |
Malignant neoplasm of upper-outer quadrant of unspecified female breast |
C50.511 |
Malignant neoplasm of lower-outer quadrant of right female breast |
C50.512 |
Malignant neoplasm of lower-outer quadrant of left female breast |
C50.519 |
Malignant neoplasm of lower-outer quadrant of unspecified female breast |
C50.611 |
Malignant neoplasm of axillary tail of right female breast |
C50.612 |
Malignant neoplasm of axillary tail of left female breast |
C50.619 |
Malignant neoplasm of axillary tail of unspecified female breast |
C50.811 |
Malignant neoplasm of overlapping sites of right female breast; |
C50.812 |
Malignant neoplasm of overlapping sites of left female breast |
C50.819 |
Malignant neoplasm of overlapping sites of unspecified female breast |
C50.911 |
Malignant neoplasm of unspecified site of right female breast |
C50.912 |
Malignant neoplasm of unspecified site of left female breast |
C50.919 |
Malignant neoplasm of unspecified site of unspecified female breast |
Malignant neoplasm of the male breast: |
|
C50.021 |
Malignant neoplasm of nipple and areola, right male breast |
C50.022 |
Malignant neoplasm of nipple and areola, left male breast |
C50.029 |
Malignant neoplasm of nipple and areola, unspecified male breast |
C50.121 |
Malignant neoplasm of central portion of right male breast |
C50.122 |
Malignant neoplasm of central portion of left male breast |
C50.129 |
Malignant neoplasm of central portion of unspecified male breast |
C50.221 |
Malignant neoplasm of upper-inner quadrant of right male breast |
C50.222 |
Malignant neoplasm of upper-inner quadrant of left male breast |
C50.229 |
Malignant neoplasm of upper-inner quadrant of unspecified male breast |
C50.321 |
Malignant neoplasm of lower-inner quadrant of right male breast |
C50.322 |
Malignant neoplasm of lower-inner quadrant of left male breast |
C50.329 |
Malignant neoplasm of lower-inner quadrant of unspecified male breast |
C50.421 |
Malignant neoplasm of upper-outer quadrant of right male breast |
C50.422 |
Malignant neoplasm of upper-outer quadrant of left male breast |
C50.429 |
Malignant neoplasm of upper-outer quadrant of unspecified male breast |
C50.521 |
Malignant neoplasm of lower-outer quadrant of right male breast |
C50.522 |
Malignant neoplasm of lower-outer quadrant of left male breast |
C50.529 |
Malignant neoplasm of lower-outer quadrant of unspecified male breast |
C50.621 |
Malignant neoplasm of axillary tail of right male breast |
C50.622 |
Malignant neoplasm of axillary tail of left male breast |
C50.629 |
Malignant neoplasm of axillary tail of unspecified male breast |
C50.821 |
Malignant neoplasm of overlapping sites of right male breast |
C50.822 |
Malignant neoplasm of overlapping sites of left male breast |
C50.829 |
Malignant neoplasm of overlapping sites of unspecified male breast |
C50.921 |
Malignant neoplasm of unspecified site of right male breast |
C50.922 |
Malignant neoplasm of unspecified site of left male breast |
C50.929 |
Malignant neoplasm of unspecified site of unspecified male breast |
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mL
- The maximum reimbursement rate per unit is: $914.87
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 50242-0245-01, 50242-0260-01
- 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