Lutetium Lu 177 Vipivotide Tetraxetan Injection, for Intravenous Use (Pluvicto™) HCPCS Code A9699: Billing Guidelines Medicaid and NC Health Choice programs covers lutetium Lu 177 vipivotide tetraxetan injection

Effective with date of service March 25, 2022, the Medicaid and NC Health Choice programs covers lutetium Lu 177 vipivotide tetraxetan injection, for intravenous use (Pluvicto) for use in the Physician’s Administered Drug Program (PADP) when billed with HCPCS code A9699 - Radiopharmaceutical, therapeutic, not otherwise classified.

Strength/Package Size: Injection: 1,000 MBq/mL (27 mCi/mL) in a single-dose vial.

Pluvicto is a radioligand therapeutic agent indicated for the treatment of adult patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer (mCRPC) who have been treated with androgen receptor (AR) pathway inhibition and taxane-based chemotherapy.

Recommended Dosage: Administer 7.4 GBq (200 mCi) every six weeks for up to six doses. See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

• Providers must bill the product with HCPCS code: A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified
• Providers must indicate the number of HCPCS units.
• One Medicaid and Health Choice unit of coverage is: 1 mCi
• The maximum reimbursement rate per unit is: $229.50
• Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 69488-0010-61
• 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