Pemetrexed Injection (Pemfexy™) HCPCS Code J9304: Billing Guidelines
Effective with date of service Feb 1, 2022, the Medicaid and NC Health Choice programs cover pemetrexed injection, for intravenous use (Pemfexy™).

Effective with date of service Feb 1, 2022, the Medicaid and NC Health Choice programs cover pemetrexed injection, for intravenous use (Pemfexy™).

Effective with date of service Feb 1, 2022, the Medicaid and NC Health Choice programs cover pemetrexed injection, for intravenous use (Pemfexy™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9304 - Injection, pemetrexed (Pemfexy™), 10 mg.

Strength/Package Size: Injection: 500 mg/20 mL (25 mg/mL) in a single-dose vial

Indicated:

  • in combination with cisplatin for the initial treatment of patients with locally advanced or metastatic non-squamous, non-small cell lung cancer (NSCLC).
  • as a single agent for the maintenance treatment of patients with locally advanced or metastatic non-squamous NSCLC whose disease has not progressed after four cycles of platinum-based first-line chemotherapy.
  • as a single agent for the treatment of patients with recurrent, metastatic non-squamous NSCLC after prior chemotherapy.
  • Limitations of Use: Pemfexy™ is not indicated for the treatment of patients with squamous cell non-small cell lung cancer.
  • in combination with cisplatin for the initial treatment of patients with malignant pleural mesothelioma whose disease is unresectable or who are otherwise not candidates for curative surgery.

Recommended Dose: 500 mg/m^2 as an intravenous infusion over 10 minutes on Day 1 of each 21-day cycle, administered as a single agent or with cisplatin, in patients with creatinine clearance of 45 mL/minute or greater. See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis codes required for billing are:  
    • C34.01 - Malignant neoplasm of right main bronchus; 
    • C34.02 - Malignant neoplasm of left main bronchus; 
    • C34.11 - Malignant neoplasm of upper lobe, right bronchus or lung; 
    • C34.12 - Malignant neoplasm of upper lobe, left bronchus or lung; 
    • C34.2 - Malignant neoplasm of middle lobe, bronchus or lung; 
    • C34.31 - Malignant neoplasm of lower lobe, right bronchus or lung; 
    • C34.32 - Malignant neoplasm of lower lobe, left bronchus or lung; 
    • C34.81 - Malignant neoplasm of overlapping sites of right bronchus and lung; 
    • C34.82 - Malignant neoplasm of overlapping sites of left bronchus and lung; 
    • C34.91 - Malignant neoplasm of unspecified part of right bronchus or lung; 
    • C34.92 - Malignant neoplasm of unspecified part of left bronchus or lung;   
    • C38.4 - Malignant neoplasm of pleura; 
    • C38.8 - Malignant neoplasm of overlapping sites of heart, mediastinum and pleura; 
    • C45.0 - Mesothelioma of pleura
  • Providers must bill with HCPCS code: J9304 - Injection, pemetrexed (Pemfexy™), 10 mg
  • One Medicaid and NC Health Choice unit of coverage is: 10 mg 
  • The maximum reimbursement rate per unit is: $83.10
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 42367-0531-33
  • 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

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