Effective with date of service Feb. 7, 2022, the Medicaid and NC Health Choice programs cover faricimab-svoa injection, for intravitreal use (Vabysmo™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size: Injection: 120 mg/mL solution in a single-dose vial
Indicated for the treatment of patients with:
- Neovascular (Wet) Age-Related Macular Degeneration (nAMD)
- Diabetic Macular Edema (DME)
Recommended Dose:
Neovascular (Wet) Age-Related Macular Degeneration (nAMD)
- 6 mg (0.05 mL of 120 mg/mL solution) administered by intravitreal injection every four weeks (approximately every 28 ± 7 days, monthly) for the first four doses, followed by optical coherence tomography and visual acuity evaluations eight and 12 weeks later to inform whether to give a 6 mg dose via intravitreal injection on one of the following three regimens:
- Weeks 28 and 44;
- Weeks 24, 36 and 48; or
- Weeks 20, 28, 36 and 44.
- Although additional efficacy was not demonstrated in most patients when Vabysmo™ was dosed every four weeks compared to every eight weeks, some patients may need every four-week (monthly) dosing after the first four doses. Patients should be assessed regularly.
Diabetic Macular Edema (DME)
- One of these two dose regimens:
- 6 mg (0.05 mL of 120 mg/mL solution) administered by intravitreal injection every four weeks (approximately every 28 days ± 7 days, monthly) for at least four doses. If, after at least four doses, resolution of edema based on the central subfield thickness (CST) of the macula as measured by optical coherence tomography is achieved, then the interval of dosing may be modified by extensions of up to four-week interval increments or reductions of up to eight-week interval increments based on CST and visual acuity evaluations through week 52; or
- 6 mg dose of Vabysmo™ can be administered every four weeks for the first six doses, followed by 6 mg dose via intravitreal injection at intervals of every eight weeks (two months) over the next 28 weeks.
- Although additional efficacy was not demonstrated in most patients when Vabysmo™ was dosed every four weeks compared to every eight weeks, some patients may need every four-week (monthly) dosing after the first four doses. Patients should be assessed regularly.
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
nAMD
- 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;
DME
- E08.311 - Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema;
- E08.3211 - Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye;
- E08.3212 - Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye;
- E08.3213 - Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral;
- E08.3311 - Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye;
- E08.3312 - Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye;
- E08.3313 - Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral;
- E08.3411 - Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye;
- E08.3412 - Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye;
- E08.3413 - Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral;
- E08.3511 - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye;
- E08.3512 - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye;
- E08.3513 - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral;
- E09.311 - Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema;
- E09.3211 - Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye;
- E09.3212 - Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye;
- E09.3213 - Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral;
- E09.3311 - Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye;
- E09.3312 - Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye;
- E09.3313 - Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral;
- E09.3411 - Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye;
- E09.3412 - Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye;
- E09.3413 - Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral;
- E09.3511 - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
- E09.3512 - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
- E09.3513 - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
- E10.311 - Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema;
- E10.3211 - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye;
- E10.3212 - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye;
- E10.3213 - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral;
- E10.3311 - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye;
- E10.3312 - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye;
- E10.3313 - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral;
- E10.3411 - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye;
- E10.3412 - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye;
- E10.3413 - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral;
- E10.3511 - Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
- E10.3512 - Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
- E10.3513 - Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
- E11.311 - Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema;
- E11.3211 - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye;
- E11.3212 - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye;
- E11.3213 - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral;
- E11.3311 - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye;
- E11.3312 - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye;
- E11.3313 - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral;
- E11.3411 - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye;
- E11.3412 - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye;
- E11.3413 - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral;
- E11.3511 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
- E11.3512 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
- E11.3513 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
- E13.311 - Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema;
- E13.3211 - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye;
- E13.3212 - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye;
- E13.3213 - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral;
- E13.3311 - Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye;
- E13.3312 - Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye;
- E13.3313 - Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral;
- E13.3411 - Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye;
- E13.3412 - Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye;
- E13.3413 - Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral;
- E13.3511 - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
- E13.3512 - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
- E13.3513 - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
- 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: $394.20
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 50242-0096-01
- 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