Selexipag for Injection, for Intravenous Use (Uptravi®) HCPCS Code J3490: Billing Guidelines
Effective with date of service Aug. 27, 2021, NC Medicaid covers selexipag for injection

Effective with date of service Aug. 27, 2021, NC Medicaid covers selexipag for injection.

Effective with date of service Aug. 27, 2021, the Medicaid and NC Health Choice programs cover selexipag for injection, for intravenous use (Uptravi) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.

Strength/Package Size(s): For Injection: 1800 mcg of selexipag as a lyophilized powder in a single dose vial for reconstitution and dilution

Indicated for the treatment of pulmonary arterial hypertension (PAH, WHO Group I) to delay disease progression and reduce the risk of hospitalization for PAH. Use Uptravi for injection in patients who are temporarily unable to take oral therapy. 

Recommended Dose: Administer Uptravi for injection twice daily by intravenous infusion at a dose that corresponds to the patient’s current dose of Uptravi tablets. See full prescribing information for further detail.

  • 200 mcg tablet dose - 225 mcg IV
  • 400 mcg tablet dose - 450 mcg IV
  • 600 mcg tablet dose - 675 mcg IV
  • 800 mcg tablet dose - 900 mcg IV
  • 1000 mcg tablet dose - 1125 mcg IV
  • 1200 mcg tablet dose - 1350 mcg IV
  • 1400 mcg tablet dose - 1575 mcg IV
  • 1600 mcg tablet dose - 1800 mcg IV

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis code(s) required for billing is:  
    • I27.0 - Primary pulmonary hypertension; 
    • I27.20 - Pulmonary hypertension, unspecified; 
    • I27.21 - Secondary pulmonary arterial hypertension; 
    • I27.22 - Pulmonary hypertension due to left heart disease; 
    • I27.23 - Pulmonary hypertension due to lung diseases and hypoxia; 
    • I27.24 - Chronic thromboembolic pulmonary hypertension; 
    • I27.29 - Other secondary pulmonary hypertension
  • Providers must bill with HCPCS code: J3490 - Unclassified drugs
  • One Medicaid and NC Health Choice unit of coverage is: 1 mcg 
  • The maximum reimbursement rate per unit is: $0.19
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is: 66215-0718-01
  • 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.

Contact

NCTracks Call Center: 800-688-6696

Related Topics: