Effective with date of service March 2, 2022, the Medicaid and NC Health Choice programs cover plasminogen, human-tvmh lyophilized powder for reconstitution, for intravenous use (Ryplazim®) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size: Single-dose 50-mL vial containing 68.8 mg of plasminogen as a lyophilized powder for reconstitution with 12.5 mL of Sterile Water for Injection, USP (SWFI)
Indicated for the treatment of patients with plasminogen deficiency type 1 (hypoplasminogenemia).
Recommended Dose: 6.6 mg/kg body weight given every two to four days. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code required for billing is: E88.02 - Plasminogen deficiency
- Providers must bill with HCPCS code: J3590 - Unclassified biologics
- One Medicaid and NC Health Choice unit of coverage is: 68.8 mg (1 single-dose vial)
- The maximum reimbursement rate per unit is: $2,229.12
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 70573-0099-01, 70573-0099-02
- 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