Satralizumab-mwge Injection, for Subcutaneous Use (Enspryng™) HCPCS Code J3590: Billing Guidelines

Tuesday, October 13, 2020

Effective with date of service Aug. 24, 2020, the NC Medicaid and NC Health Choice programs cover satralizumab-mwge injection, for subcutaneous use (Enspryng™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.

Strength/Package Size:  Injection: 120 mg/mL in a single-dose prefilled syringe

Indicated for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody positive.

Recommended Dose:  120 mg by subcutaneous injection at Weeks 0, 2 and 4, followed by a maintenance dosage of 120 mg every 4 weeks. See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis code required for billing is: G36.0 - Neuromyelitis optica [Devic]
  • 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: $131.54
  • Providers must bill 11-digit NDCs and appropriate NDC units.  The NDC(s) is/are: 50242-0007-01
  • 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 NC 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 NC Medicaid's PADP web page.

Contact
NCTracks Contact Center: 800-688-6696