Effective with date of service March 15, 2022, the Medicaid and NC Health Choice programs cover naloxone hydrochloride injection for intramuscular or subcutaneous use (Zimhi™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Size: Injection: 5 mg/0.5 mL naloxone hydrochloride solution in a single-dose, prefilled syringe
Indicated in adult and pediatric patients for the emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression.
Recommended Dose
Each Zimhi™ contains a single dose of naloxone hydrochloride for single-dose injection.
Initial Dosing (See full prescribing information for further detail)
Administer the initial dose of Zimhi™ to adult or pediatric patients intramuscularly or subcutaneously into the anterolateral aspect of the thigh, through clothing if necessary, and seek emergency medical assistance. Administer Zimhi™ as quickly as possible because prolonged respiratory depression may result in damage to the central nervous system or death.
Repeat Dosing
The requirement for repeat doses of Zimhi™ depends upon the amount, type, and route of administration of the opioid being antagonized. If the desired response is not obtained after 2 or 3 minutes, an additional dose of Zimhi™ may be administered. If there is still no response and additional doses are available, additional doses of Zimhi™ may be administered every two to three minutes until emergency medical assistance arrives.
If the patient responds to Zimhi™ and relapses back into respiratory depression before emergency assistance arrives, administer an additional dose of Zimhi™ and continue surveillance of the patient after administering an additional dose.
Dosing in Pediatric Patients under Age One Year
In pediatric patients under the age of one year, the caregiver should pinch the thigh muscle while administering Zimhi. Carefully observe the administration site for signs of infection following resolution of the opioid emergency.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- T40.0X1A - Poisoning by opium, accidental (unintentional), initial encounter;
- T40.0X1D - Poisoning by opium, accidental (unintentional), subsequent encounter;
- T40.0X1S - Poisoning by opium, accidental (unintentional), sequela;
- T40.0X2A - Poisoning by opium, intentional self-harm, initial encounter;
- T40.0X2D - Poisoning by opium, intentional self-harm, subsequent encounter;
- T40.0X2S - Poisoning by opium, intentional self-harm, sequela;
- T40.0X3A - Poisoning by opium, assault, initial encounter;
- T40.0X3D - Poisoning by opium, assault, subsequent encounter;
- T40.0X3S - Poisoning by opium, assault, sequela;
- T40.0X4A - Poisoning by opium, undetermined, initial encounter;
- T40.0X4D - Poisoning by opium, undetermined, subsequent encounter;
- T40.0X4S - Poisoning by opium, undetermined, sequela;
- T40.1X1A - Poisoning by heroin, accidental (unintentional), initial encounter;
- T40.1X1D - Poisoning by heroin, accidental (unintentional), subsequent encounter;
- T40.1X1S - Poisoning by heroin, accidental (unintentional), sequela;
- T40.1X2A - Poisoning by heroin, intentional self-harm, initial encounter;
- T40.1X2D - Poisoning by heroin, intentional self-harm, subsequent encounter;
- T40.1X2S - Poisoning by heroin, intentional self-harm, sequela;
- T40.1X3A - Poisoning by heroin, assault, initial encounter;
- T40.1X3D - Poisoning by heroin, assault, subsequent encounter;
- T40.1X3S - Poisoning by heroin, assault, sequela;
- T40.1X4A - Poisoning by heroin, undetermined, initial encounter;
- T40.1X4D - Poisoning by heroin, undetermined, subsequent encounter;
- T40.1X4S - Poisoning by heroin, undetermined, sequela;
- T40.2X1A - Poisoning by other opioids, accidental (unintentional), initial encounter;
- T40.2X1D - Poisoning by other opioids, accidental (unintentional), subsequent encounter;
- T40.2X1S - Poisoning by other opioids, accidental (unintentional), sequela;
- T40.2X2A - Poisoning by other opioids, intentional self-harm, initial encounter;
- T40.2X2D - Poisoning by other opioids, intentional self-harm, subsequent encounter;
- T40.2X2S - Poisoning by other opioids, intentional self-harm, sequela;
- T40.2X3A - Poisoning by other opioids, assault, initial encounter;
- T40.2X3D - Poisoning by other opioids, assault, subsequent encounter;
- T40.2X3S - Poisoning by other opioids, assault, sequela;
- T40.2X4A - Poisoning by other opioids, undetermined, initial encounter;
- T40.2X4D - Poisoning by other opioids, undetermined, subsequent encounter;
- T40.2X4S - Poisoning by other opioids, undetermined, sequela;
- T40.3X1A - Poisoning by methadone, accidental (unintentional), initial encounter;
- T40.3X1D - Poisoning by methadone, accidental (unintentional), subsequent encounter;
- T40.3X1S - Poisoning by methadone, accidental (unintentional), sequela;
- T40.3X2A - Poisoning by methadone, intentional self-harm, initial encounter;
- T40.3X2D - Poisoning by methadone, intentional self-harm, subsequent encounter;
- T40.3X2S - Poisoning by methadone, intentional self-harm, sequela;
- T40.3X3A - Poisoning by methadone, assault, initial encounter;
- T40.3X3D - Poisoning by methadone, assault, subsequent encounter;
- T40.3X3S - Poisoning by methadone, assault, sequela;
- T40.3X4A - Poisoning by methadone, undetermined, initial encounter;
- T40.3X4D - Poisoning by methadone, undetermined, subsequent encounter;
- T40.3X4S - Poisoning by methadone, undetermined, sequela;
- T40.411A - Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter;
- T40.411D - Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter;
- T40.411S - Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), sequela;
- T40.412A - Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter;
- T40.412D - Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter;
- T40.412S - Poisoning by fentanyl or fentanyl analogs, intentional self-harm, sequela;
- T40.413A - Poisoning by fentanyl or fentanyl analogs, assault, initial encounter;
- T40.413D - Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter;
- T40.413S - Poisoning by fentanyl or fentanyl analogs, assault, sequela;
- T40.414A - Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter;
- T40.414D - Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter;
- T40.414S - Poisoning by fentanyl or fentanyl analogs, undetermined, sequela;
- T40.421A - Poisoning by tramadol, accidental (unintentional), initial encounter;
- T40.421D - Poisoning by tramadol, accidental (unintentional), subsequent encounter;
- T40.421S - Poisoning by tramadol, accidental (unintentional), sequela;
- T40.422A - Poisoning by tramadol, intentional self-harm, initial encounter;
- T40.422D - Poisoning by tramadol, intentional self-harm, subsequent encounter;
- T40.422S - Poisoning by tramadol, intentional self-harm, sequela;
- T40.423A - Poisoning by tramadol, assault, initial encounter;
- T40.423D - Poisoning by tramadol, assault, subsequent encounter;
- T40.423S - Poisoning by tramadol, assault, sequela;
- T40.424A - Poisoning by tramadol, undetermined, initial encounter;
- T40.424D - Poisoning by tramadol, undetermined, subsequent encounter;
- T40.424S - Poisoning by tramadol, undetermined, sequela;
- T40.491A - Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter;
- T40.491D - Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter;
- T40.491S - Poisoning by other synthetic narcotics, accidental (unintentional), sequela;
- T40.492A - Poisoning by other synthetic narcotics, intentional self-harm, initial encounter;
- T40.492D - Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter;
- T40.492S - Poisoning by other synthetic narcotics, intentional self-harm, sequela;
- T40.493A - Poisoning by other synthetic narcotics, assault, initial encounter;
- T40.493D - Poisoning by other synthetic narcotics, assault, subsequent encounter;
- T40.493S - Poisoning by other synthetic narcotics, assault, sequela;
- T40.494A - Poisoning by other synthetic narcotics, undetermined, initial encounter;
- T40.494D - Poisoning by other synthetic narcotics, undetermined, subsequent encounter;
- T40.494S - Poisoning by other synthetic narcotics, undetermined, sequela;
- T40.601A - Poisoning by unspecified narcotics, accidental (unintentional), initial encounter;
- T40.601D - Poisoning by unspecified narcotics, accidental (unintentional), subsequent encounter;
- T40.601S - Poisoning by unspecified narcotics, accidental (unintentional), sequela;
- T40.602A - Poisoning by unspecified narcotics, intentional self-harm, initial encounter;
- T40.602D - Poisoning by unspecified narcotics, intentional self-harm, subsequent encounter;
- T40.602S - Poisoning by unspecified narcotics, intentional self-harm, sequela;
- T40.603A - Poisoning by unspecified narcotics, assault, initial encounter;
- T40.603D - Poisoning by unspecified narcotics, assault, subsequent encounter;
- T40.603S - Poisoning by unspecified narcotics, assault, sequela;
- T40.604A - Poisoning by unspecified narcotics, undetermined, initial encounter;
- T40.604D - Poisoning by unspecified narcotics, undetermined, subsequent encounter;
- T40.604S - Poisoning by unspecified narcotics, undetermined, sequela;
- T40.691A - Poisoning by other narcotics, accidental (unintentional), initial encounter;
- T40.691D - Poisoning by other narcotics, accidental (unintentional), subsequent encounter;
- T40.691S - Poisoning by other narcotics, accidental (unintentional), sequela;
- T40.692A - Poisoning by other narcotics, intentional self-harm, initial encounter;
- T40.692D - Poisoning by other narcotics, intentional self-harm, subsequent encounter;
- T40.692S - Poisoning by other narcotics, intentional self-harm, sequela;
- T40.693A - Poisoning by other narcotics, assault, initial encounter;
- T40.693D - Poisoning by other narcotics, assault, subsequent encounter;
- T40.693S - Poisoning by other narcotics, assault, sequela;
- T40.694A - Poisoning by other narcotics, undetermined, initial encounter;
- T40.694D - Poisoning by other narcotics, undetermined, subsequent encounter;
- T40.694S - Poisoning by other narcotics, undetermined, sequela
- 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: $13.50
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 78670-0140-02, 78670-0140-11
- 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 Contact Center: 800-688-6696