Effective with date of service Jan. 1, 2022, the Medicaid and NC Health Choice programs covers kit for the preparation of gallium Ga 68 dotatate injection, for intravenous use (Netspot) for use in the Physician’s Administered Drug Program (PADP) when billed with HCPCS code A9587 - Gallium Ga-68, dotatate, diagnostic, 0.1 millicurie.
Strength/Package Size: Netspot is supplied as a single dose kit containing:
- Vial 1 (reaction vial with lyophilized powder) containing 40 mcg of dotatate.
- Vial 2 (buffer vial) containing 1 mL of reaction buffer solution.
After reconstitution with Ga 68 and pH adjustment with Reaction Buffer, Vial 1 contains a sterile solution of Ga 68 dotatate at a strength up to 218 MBq/mL (5.89 mCi/mL).
Netspot, after radiolabeling with Ga 68, is a radioactive diagnostic agent indicated for use with positron emission tomography (PET) for localization of somatostatin receptor positive neuroendocrine tumors (NETs) in adult and pediatric patients.
The recommended dose of Netspot is 2 MBq/kg (0.054 mCi/kg) of body weight up to 200 MBq (5.4 mCi) administered as intravenous bolus injection. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- Providers must bill the product with HCPCS code: A9587 - Gallium Ga-68, dotatate, diagnostic, 0.1 millicurie.
- Providers must indicate the number of HCPCS units.
- One Medicaid and NC Health Choice unit of coverage is: 0.1 mCi
- The maximum reimbursement rate per unit is: $55.01
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 69488-0001-40
- 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