Effective with date of service May 17, 2021, the Medicaid and NC Health Choice programs cover dostarlimab-gxly injection, for intravenous use (Jemperli) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Jemperli is available as a 500 mg/10 mL (50 mg/mL) solution for injection in a single-dose vial.
Jemperli is indicated for the treatment of adult patients with mismatch repair deficient (dMMR) recurrent or advanced endometrial cancer, as determined by an FDA-approved test, that has progressed on or following prior treatment with a platinum-containing regimen.
Recommended Dose (see full prescribing information for further detail):
- Dose 1 through 4: 500 mg every three weeks
- Subsequent dosing beginning three weeks after Dose 4 (Dose 5 onwards): 1,000 mg every six weeks
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing is: C54.1 - Malignant neoplasm of endometrium
- 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: $22.40
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is:00173-0898-03
- 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 Call Center: 800-688-6696