Effective with date of service June 22, 2022, the Medicaid and NC Health Choice programs cover Nalmefene hydrochloride injection (Revex™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490.
Nalmefene is available as a single-dose vial injection 2 mL of 1 mg/mL.
Nalmefene is indicated for the treatment of patients with, for the complete or partial reversal of opioid drug effects, including respiratory depression, induced by either natural or synthetic opioids in the management of known or suspected opioid overdose.
Recommended Doses of Nalmefene are, Reversal of Postoperative Opioid Depression:
The goal of treatment with Revex in the postoperative setting is to achieve reversal of excessive opioid effects without inducing a complete reversal and acute pain. This is best accomplished with an initial dose of 0.25 µg/kg followed by 0.25 µg/kg incremental doses at 2-5minute intervals, stopping as soon as the desired degree of opioid reversal is obtained. A cumulative total dose above 1.0 µg/kg does not provide additional therapeutic effect.
- Body weight = 50 kg, dose = 0.125 mL
- Body weight = 60 kg, dose = 0.150 mL
- Body weight = 70 kg, dose = 0.175 mL
- Body weight = 80 kg, dose = 0.200 mL
- Body weight = 90 kg, dose = 0.225 mL
- Body weight = 100 kg, dose = 0.250 mL
Management of Known or Suspected Opioid Overdose:
- Use 1.0 mg/mL dosage strength (green label).
- The recommended initial dose of Revex for non-opioid dependent patients is 0.5 mg/70 kg. If needed, this may be followed by a second dose of 1.0 mg/70 kg, 2 to 5 minutes later.
- If a total dose of 1.5 mg /70 kg has been administered without clinical response, additional Revex (Nalmefene hydrochloride injection) is unlikely to have an effect.
- Patients should not be given more Revex than is required to restore the respiratory rate to normal, thus minimizing the likelihood of cardiovascular stress and precipitated withdrawal syndrome.
- If there is a reasonable suspicion of opioid dependency, a challenge dose of Revex 0.1 mg/70 kg should be administered initially. If there is no evidence of withdrawal in 2 minutes, the recommended dosing should be followed.
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are:
- T40.0X1A - Poisoning by opium, accidental (unintentional), initial encounter;
- T40.0X1D - Poisoning by opium, accidental (unintentional), subsequent encounter;
- T40.0X1S - Poisoning by opium, accidental (unintentional), sequela;
- T40.0X2A - Poisoning by opium, intentional self-harm, initial encounter;
- T40.0X2D - Poisoning by opium, intentional self-harm, subsequent encounter;
- T40.0X2S - Poisoning by opium, intentional self-harm, sequela;
- T40.0X3A - Poisoning by opium, assault, initial encounter;
- T40.0X3D - Poisoning by opium, assault, subsequent encounter;
- T40.0X3S - Poisoning by opium, assault, sequela;
- T40.0X4A - Poisoning by opium, undetermined, initial encounter;
- T40.0X4D - Poisoning by opium, undetermined, subsequent encounter;
- T40.0X4S - Poisoning by opium, undetermined, sequela;
- T40.1X1A - Poisoning by heroin, accidental (unintentional), initial encounter;
- T40.1X1D - Poisoning by heroin, accidental (unintentional), subsequent encounter;
- T40.1X1S - Poisoning by heroin, accidental (unintentional), sequela;
- T40.1X2A - Poisoning by heroin, intentional self-harm, initial encounter;
- T40.1X2D - Poisoning by heroin, intentional self-harm, subsequent encounter;
- T40.1X2S - Poisoning by heroin, intentional self-harm, sequela;
- T40.1X3A - Poisoning by heroin, assault, initial encounter;
- T40.1X3D - Poisoning by heroin, assault, subsequent encounter;
- T40.1X3S - Poisoning by heroin, assault, sequela;
- T40.1X4A - Poisoning by heroin, undetermined, initial encounter;
- T40.1X4D - Poisoning by heroin, undetermined, subsequent encounter;
- T40.1X4S - Poisoning by heroin, undetermined, sequela;
- T40.2X1A - Poisoning by other opioids, accidental (unintentional), initial encounter;
- T40.2X1D - Poisoning by other opioids, accidental (unintentional), subsequent encounter;
- T40.2X1S - Poisoning by other opioids, accidental (unintentional), sequela;
- T40.2X2A - Poisoning by other opioids, intentional self-harm, initial encounter;
- T40.2X2D - Poisoning by other opioids, intentional self-harm, subsequent encounter;
- T40.2X2S - Poisoning by other opioids, intentional self-harm, sequela;
- T40.2X3A - Poisoning by other opioids, assault, initial encounter;
- T40.2X3D - Poisoning by other opioids, assault, subsequent encounter;
- T40.2X3S - Poisoning by other opioids, assault, sequela;
- T40.2X4A - Poisoning by other opioids, undetermined, initial encounter;
- T40.2X4D - Poisoning by other opioids, undetermined, subsequent encounter;
- T40.2X4S - Poisoning by other opioids, undetermined, sequela;
- T40.3X1A - Poisoning by methadone, accidental (unintentional), initial encounter;
- T40.3X1D - Poisoning by methadone, accidental (unintentional), subsequent encounter;
- T40.3X1S - Poisoning by methadone, accidental (unintentional), sequela;
- T40.3X2A - Poisoning by methadone, intentional self-harm, initial encounter;
- T40.3X2D - Poisoning by methadone, intentional self-harm, subsequent encounter;
- T40.3X2S - Poisoning by methadone, intentional self-harm, sequela;
- T40.3X3A - Poisoning by methadone, assault, initial encounter;
- T40.3X3D - Poisoning by methadone, assault, subsequent encounter;
- T40.3X3S - Poisoning by methadone, assault, sequela;
- T40.3X4A - Poisoning by methadone, undetermined, initial encounter;
- T40.3X4D - Poisoning by methadone, undetermined, subsequent encounter;
- T40.3X4S - Poisoning by methadone, undetermined, sequela;
- T40.411A - Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter;
- T40.411D - Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter;
- T40.411S - Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), sequela;
- T40.412A - Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter;
- T40.412D - Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter;
- T40.412S - Poisoning by fentanyl or fentanyl analogs, intentional self-harm, sequela;
- T40.413A - Poisoning by fentanyl or fentanyl analogs, assault, initial encounter;
- T40.413D - Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter;
- T40.413S - Poisoning by fentanyl or fentanyl analogs, assault, sequela;
- T40.414A - Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter;
- T40.414D - Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter;
- T40.414S - Poisoning by fentanyl or fentanyl analogs, undetermined, sequela;
- T40.421A - Poisoning by tramadol, accidental (unintentional), initial encounter;
- T40.421D - Poisoning by tramadol, accidental (unintentional), subsequent encounter;
- T40.421S - Poisoning by tramadol, accidental (unintentional), sequela;
- T40.422A - Poisoning by tramadol, intentional self-harm, initial encounter;
- T40.422D - Poisoning by tramadol, intentional self-harm, subsequent encounter;
- T40.422S - Poisoning by tramadol, intentional self-harm, sequela;
- T40.423A - Poisoning by tramadol, assault, initial encounter;
- T40.423D - Poisoning by tramadol, assault, subsequent encounter;
- T40.423S - Poisoning by tramadol, assault, sequela;
- T40.424A - Poisoning by tramadol, undetermined, initial encounter;
- T40.424D - Poisoning by tramadol, undetermined, subsequent encounter;
- T40.424S - Poisoning by tramadol, undetermined, sequela;
- T40.491A - Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter;
- T40.491D - Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter;
- T40.491S - Poisoning by other synthetic narcotics, accidental (unintentional), sequela;
- T40.492A - Poisoning by other synthetic narcotics, intentional self-harm, initial encounter;
- T40.492D - Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter;
- T40.492S - Poisoning by other synthetic narcotics, intentional self-harm, sequela;
- T40.493A - Poisoning by other synthetic narcotics, assault, initial encounter;
- T40.493D - Poisoning by other synthetic narcotics, assault, subsequent encounter;
- T40.493S - Poisoning by other synthetic narcotics, assault, sequela;
- T40.494A - Poisoning by other synthetic narcotics, undetermined, initial encounter;
- T40.494D - Poisoning by other synthetic narcotics, undetermined, subsequent encounter;
- T40.494S - Poisoning by other synthetic narcotics, undetermined, sequela;
- T40.601A - Poisoning by unspecified narcotics, accidental (unintentional), initial encounter;
- T40.601D - Poisoning by unspecified narcotics, accidental (unintentional), subsequent encounter;
- T40.601S - Poisoning by unspecified narcotics, accidental (unintentional), sequela;
- T40.602A - Poisoning by unspecified narcotics, intentional self-harm, initial encounter;
- T40.602D - Poisoning by unspecified narcotics, intentional self-harm, subsequent encounter;
- T40.602S - Poisoning by unspecified narcotics, intentional self-harm, sequela;
- T40.603A - Poisoning by unspecified narcotics, assault, initial encounter;
- T40.603D - Poisoning by unspecified narcotics, assault, subsequent encounter;
- T40.603S - Poisoning by unspecified narcotics, assault, sequela;
- T40.604A - Poisoning by unspecified narcotics, undetermined, initial encounter;
- T40.604D - Poisoning by unspecified narcotics, undetermined, subsequent encounter;
- T40.604S - Poisoning by unspecified narcotics, undetermined, sequela;
- T40.691A - Poisoning by other narcotics, accidental (unintentional), initial encounter;
- T40.691D - Poisoning by other narcotics, accidental (unintentional), subsequent encounter;
- T40.691S - Poisoning by other narcotics, accidental (unintentional), sequela;
- T40.692A - Poisoning by other narcotics, intentional self-harm, initial encounter;
- T40.692D - Poisoning by other narcotics, intentional self-harm, subsequent encounter;
- T40.692S - Poisoning by other narcotics, intentional self-harm, sequela;
- T40.693A - Poisoning by other narcotics, assault, initial encounter;
- T40.693D - Poisoning by other narcotics, assault, subsequent encounter;
- T40.693S - Poisoning by other narcotics, assault, sequela;
- T40.694A - Poisoning by other narcotics, undetermined, initial encounter;
- T40.694D - Poisoning by other narcotics, undetermined, subsequent encounter;
- T40.694S - Poisoning by other narcotics, undetermined, sequela
- Providers must bill with HCPCS code: J3490
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $16.20
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: Generic NDC: 59011-0960-10
- 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