Effective with date of service Oct. 22, 2021, Medicaid and NC Health Choice programs cover afamelanotide implant, for subcutaneous use (Scenesse®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J7352 - Afamelanotide implant, 1 mg.
Strength/Package Size: Implant:16 mg of afamelanotide
Indicated to increase pain free light exposure in adult patients with a history of phototoxic reactions from erythropoietic protoporphyria (EPP).
Recommended Dose: A single Scenesse® implant is inserted subcutaneously above the anterior supra-iliac crest every two months. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code required for billing is: E80.0 - Hereditary erythropoietic porphyria
- Providers must bill with HCPCS code: J7352 - Afamelanotide implant, 1 mg
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $3,049.48
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is: 73372-0116-01
- 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 web page
Contact
NCTracks Call Center: 800-688-6696