Effective with date of service July 15, 2021, the Medicaid and NC Health Choice programs cover asparaginase erwinia chrysanthemi (recombinant)-rywn injection, for intramuscular use (Rylaze™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Rylase™ is available as a 10 mg/0.5 mL solution in a single-dose vial and indicated as a component of a multi-agent chemotherapeutic regimen for the treatment of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) in adult and pediatric patients 1 month or older who have developed hypersensitivity to E. coli-derived asparaginase.
Recommended Dose: 25 mg/m2 administered intramuscularly every 48 hours, when replacing a long-acting asparaginase product. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are:
C91.00 - Acute lymphoblastic leukemia not having achieved remission;
C91.01 - Acute lymphoblastic leukemia, in remission;
C91.02 - Acute lymphoblastic leukemia, in relapse;
C83.50 - Lymphoblastic (diffuse) lymphoma, unspecified site;
C83.51 - Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck;
C83.52 - Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes;
C83.53 - Lymphoblastic (diffuse) lymphoma, intra- abdominal lymph nodes;
C83.54 - Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb;
C83.55 - Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb;
C83.56 - Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes;
C83.57 - Lymphoblastic (diffuse) lymphoma, spleen;
C83.58 - Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites;
C83.59 - Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites;
- 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: $474.12
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 68727-0900-01, 68727-0900-03
- 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 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 webpage.
Contact
NCTracks Call Center: 800-688-6696