Nivolumab and Relatlimab-rmbw Injection, for Intravenous Use (Opdualag™) HCPCS Code J9999: Billing Guidelines Medicaid and NC Health Choice programs cover nivolumab and relatlimab-rmbw injection

Effective with date of service April 14, 2022, the Medicaid and NC Health Choice programs cover nivolumab and relatlimab-rmbw injection, for intravenous use (Opdualag™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified anti-neoplastic drugs.

Strength/Package Size: Injection: 240 mg of nivolumab and 80 mg of relatlimab per 20 mL (12 mg and 4 mg per mL) in a single-dose vial

Indicated for the treatment of adult and pediatric patients 12 years of age or older with unresectable or metastatic melanoma.

Recommended Dose: 480 mg nivolumab and 160 mg relatlimab intravenously every four weeks. See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

• The ICD-10-CM diagnosis codes required for billing are:  
  • C43.0 - Malignant melanoma of lip;
  • C43.111 - Malignant melanoma of right upper eyelid, including canthus;
  • C43.112 - Malignant melanoma of right lower eyelid, including canthus;
  • C43.121 - Malignant melanoma of left upper eyelid, including canthus;
  • C43.122 - Malignant melanoma of left lower eyelid, including canthus;
  • C43.21 - Malignant melanoma of right ear and external auricular canal;
  • C43.22 - Malignant melanoma of left ear and external auricular canal;
  • C43.31 - Malignant melanoma of nose;
  • C43.39 - Malignant melanoma of other parts of face;
  • C43.4 - Malignant melanoma of scalp and neck;
  • C43.51 - Malignant melanoma of anal skin;
  • C43.52 - Malignant melanoma of skin of breast;
  • C43.59 - Malignant melanoma of other part of trunk;
  • C43.61 - Malignant melanoma of right upper limb, including shoulder;
  • C43.62 - Malignant melanoma of left upper limb, including shoulder;
  • C43.71 - Malignant melanoma of right lower limb, including hip;
  • C43.72 - Malignant melanoma of left lower limb, including hip;
  • C43.8 - Malignant melanoma of overlapping sites of skin
• Providers must bill with HCPCS code: J9999 - Not otherwise classified anti-neoplastic drugs
• One Medicaid and NC Health Choice unit of coverage is: 1 mL 
• The maximum reimbursement rate per unit is: $739.49 
• Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 00003-7125-11
• 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 Call Center: 800-688-6696