Effective with date of service Feb. 28, 2022, the Medicaid and NC Health Choice programs cover cabotegravir extended-release injectable suspension, for intramuscular use (Apretude) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Size: Injection: Single-dose vial of 600 mg/3 mL (200 mg/mL) of cabotegravir and extended-release injectable suspension
Indicated in at-risk adults and adolescents weighing at least 35 kg for PrEP to reduce the risk of sexually acquired HIV-1 infection.
Recommended Dose: Initiate Apretude with a single 600-mg (3-mL) injection given one month apart for two consecutive months on the last day of an oral lead-in, if used, or within three days thereafter and continue with the injections 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: Z20.6 - Contact with and (suspected) exposure to human immunodeficiency virus (HIV)
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $6.66
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 49702-0264-23, 49702-0238-01
- 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 webpage.
Contact
NCTracks Contact Center: 800-688-6696