Effective with date of service Dec. 17, 2021, the Medicaid and NC Health Choice programs cover efgartigimod alfa-fcab injection, for intravenous use (VYVGART™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size: Injection: 400 mg in 20 mL (20 mg/mL) single-dose vial
Indicated for the treatment of generalized myasthenia gravis (gMG) in adult patients who are anti-acetylcholine receptor (AChR) antibody positive.
Recommended Dose: The recommended dosage is 10 mg/kg administered as an intravenous infusion over one hour once weekly for four weeks. In patients weighing 120 kg or more, the recommended dose is 1,200 mg per infusion. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- G70.00 - Myasthenia gravis without (acute) exacerbation;
- G70.01 - Myasthenia gravis with (acute) exacerbation
- Providers must bill with HCPCS code: J3590 - Unclassified biologics
- One Medicaid and Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $16.07
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is:73475-3041-05
- 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