Effective with date of service Dec. 1, 2021, the Medicaid and NC Health Choice programs cover ranibizumab injection for intravitreal use via ocular implant (Susvimo™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size(s): Injection: 100 mg/mL solution in a single-dose vial
Indicated for the treatment of patients with Neovascular (wet) Age-related Macular Degeneration (AMD) who have previously responded to at least two intravitreal injections of a VEGF inhibitor.
Recommended Dose: The recommended dose of Susvimo is 2 mg (0.02 mL of 100 mg/mL solution) continuously delivered via the Susvimo implant with refills every 24 weeks (approximately six months). Supplemental treatment with 0.5 mg intravitreal ranibizumab injection may be administered in the affected eye if clinically necessary. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- H35.3210 - Exudative age-related macular degeneration, right eye, with stage unspecified;
- H35.3211 - Exudative age-related macular degeneration, right eye, with active choroidal neovascularization;
- H35.3212 - Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization;
- H35.3213 - Exudative age-related macular degeneration, right eye, with inactive scar;
- H35.3220 - Exudative age-related macular degeneration, left eye, with stage unspecified;
- H35.3221 - Exudative age-related macular degeneration, left eye, with active choroidal neovascularization;
- H35.3222 - Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization;
- H35.3223 - Exudative age-related macular degeneration, left eye, with inactive scar;
- H35.3230 - Exudative age-related macular degeneration, bilateral, with stage unspecified;
- H35.3231 - Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization;
- H35.3232 - Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization;
- H35.3233 - Exudative age-related macular degeneration, bilateral, with inactive scar;
- H35.3290 - Exudative age-related macular degeneration, unspecified eye, stage unspecified;
- H35.3291 - Exudative age-related macular degeneration, unspecified eye, with active choroidal neovascularization;
- H35.3292 - Exudative age-related macular degeneration, unspecified eye, with inactive choroidal neovascularization;
- H35.3293 - Exudative age-related macular degeneration, unspecified eye, inactive scar
- 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: $864.00
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 50242-0078-12, 50242-0078-55
- 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