Effective with date of service June 28, 2021, the Medicaid and NC Health Choice programs cover dasiglucagon injection, for subcutaneous use (Zegalogue®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Zegaloue® is indicated for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes aged 6 years and above.
The recommended dose of Zegalogue® in adults and pediatric patients aged 6 years and older is 0.6 mg administered by subcutaneous injection into the lower abdomen, buttocks, thigh, or outer upper arm. If there has been no response after 15 minutes, an additional 0.6 mg dose from a new device may be administered while waiting for emergency assistance. 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:
E09.649 - Drug or chemical induced diabetes mellitus with hypoglycemia without coma;
E10.649 - Type 1 diabetes mellitus with hypoglycemia without coma;
E11.649 - Type 2 diabetes mellitus with hypoglycemia without coma;
E13.649 - Other specified diabetes mellitus with hypoglycemia without coma
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 0.6 mg
- The maximum reimbursement rate per unit is: $333.72
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 80644-0012-01, 80644-0012-02, 80644-0013-01, 80644-0013-02
- 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