Skip to main content
NC Medicaid logo NC Medicaid

Topical Navigation

  • Home
  • Beneficiaries
  • Meetings & Notices
  • Find a Doctor
  • Providers
  • Counties
  • Reports
  • ABOUT US
  • NC.GOV
  • NCDHHS
  • SERVICES
NC Medicaid »   Home »   blog

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

May 10, 2022

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

This blog is related to:

  • Bulletins
  • Physicians, Physician Assistants and Nurse Practitioners

Related Articles

  • Prior Authorizations End-dated When a Beneficiary Transitions to Managed Care
  • Reminder: Orthotics and Prosthetics Providers Must Include Modifier for Appropriate HCPCS Codes
  • Outpatient Specialized Therapies Prior Authorization (PA) Update
  • SPECIAL BULLETIN COVID-19 #249: Pfizer-BioNTech Vaccine Booster Dose for Children Age 5 through 11
  • New Billing Codes for Social Drivers of Health
  • SPECIAL BULLETIN COVID-19 #248: Telehealth Flexibilities for Occupational and Physical Therapies
  • Shared/Split Evaluation and Management Visits
  • Updates to Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies
  • Billing Requirement Modifications Due to COVID-19 to Expire
  • Verifying Provider Information (NPI+Location Code) in NCTracks
  • Lutetium Lu 177 Vipivotide Tetraxetan Injection, for Intravenous Use (Pluvicto™) HCPCS Code A9699: Billing Guidelines
  • Kit for the Preparation of Gallium Ga 68 Dotatate Injection, for Intravenous Use (Netspot®) HCPCS Code A9587: Billing Guidelines
  • Kit for the Preparation of Gallium Ga 68 Gozetotide Injection, for Intravenous Use (Locametz®) HCPCS Code A9597: Billing Guidelines
  • Gadoterate Meglumine Injection, for Intravenous Use (Clariscan™) HCPCS Code A9575: Billing Guidelines
  • Free Dental Continuing Education Credits

Share this page:

  • Facebook
  • Twitter
  • Email
Back to top

Contact Information

NC Medicaid
Division of Health Benefits

2501 Mail Service Center
Raleigh, NC 27699-2501
 
NC Medicaid Contact Center
Phone: 888-245-0179
Monday-Friday 8 a.m. to 5 p.m.
Closed on State holidays. 
 
Visit RelayNC for information about TTY services. 
 
More
 

Recent Tweets

Tweets by @ncdhhs

Follow Us

  • Facebook
  • Twitter
  • YouTube
  • LinkedIn
  • EMPLOYEE DIRECTORY
  • TRANSLATION DISCLAIMER
  • Accessibility
  • Terms of Use
  • Privacy Policy
  • Open Budget
NC Medicaid
https://medicaid.ncdhhs.gov/blog/2022/05/10/lutetium-lu-177-vipivotide-tetraxetan-injection-intravenous-use-pluvictotm-hcpcs-code-a9699-billing