Amivantamab-vmjw Injection, for Intravenous Use (Rybrevant™) HCPCS Code J9999: Billing Guidelines

Effective with date of service June 9, 2021, the Medicaid and NC Health Choice programs cover amivantamab-vmjw injection, for intravenous use (Rybrevant) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 – Not otherwise classified antineoplastic drugs.

Effective with date of service June 9, 2021, the Medicaid and NC Health Choice programs cover amivantamab-vmjw injection, for intravenous use (Rybrevant) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 – Not otherwise classified antineoplastic drugs.

Rybrevant is available as an injection of 350 mg/7 mL (50 mg/mL) solution in a single-dose vial.

Rybrevant is indicated for the treatment of adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations, as detected by an FDA-approved test, whose disease has progressed on or after platinum-based chemotherapy.

Recommended Dose (based on baseline body weight, see full prescribing information for further detail):

Body weight less than 80 kg: 1,050 mg (3 vials)

Body weight greater than or equal to 80 kg:1,400 mg (4 vials)

Administer Rybrevant weekly for four weeks, with the initial dose as a split infusion in Week 1 on Day 1 and Day 2, then administer every two weeks thereafter.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis code(s) required for billing is/are: 
    • 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 unspecified 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 Health Choice unit of coverage is: 1 mg
  • The maximum reimbursement rate per unit is: $9.22
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 57894-0501-00, 57894-0501-01
  • The NDC units should be reported as “UN1”
  • For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and 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 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 Medicaid's PADP webpage.

Contact

NCTracks Call Center: 800-688-6696

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