Avalglucosidase alfa-ngpt for Injection, for Intravenous Use (Nexviazyme™) HCPCS Code J3590: Billing Guidelines Effective with date of service Aug. 10, 2021, NC Medicaid covers avalglucosidase alfa-ngpt for injection
Effective with date of service Aug. 10, 2021, the Medicaid and NC Health Choice programs cover avalglucosidase alfa-ngpt for injection, for intravenous use (Nexviazyme™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size(s): For injection: 100 mg of avalglucosidase alfa-ngpt as a lyophilized powder in a single-dose vial for reconstitution
Indicated for the treatment of patients one year of age and older with late-onset Pompe disease (lysosomal acid alpha-glucosidase [GAA] deficiency).
Recommended Dose: See full prescribing information for further detail.
- ≥30 kg, the recommended dosage is 20 mg/kg (of actual body weight) as an intravenous infusion every two weeks.
- <30 kg, the recommended dosage is 40 mg/kg (of actual body weight) as an intravenous infusion every two weeks.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is:
- E74.02 - Pompe disease
- 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: $18.52
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 58468-0426-01
- 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 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.
NCTracks Call Center: 800-688-6696