Effective with date of service Oct. 1, 2022, the Medicaid and NC Health Choice programs cover Albuterol Sulfate inhalation solution (0.021%, 0.042% and 0.083%) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J7613 - Albuterol, inhalation solution, FDA-approved final product, non-compounded, unit dose, 1 mg
Strength/Package Size: Albuterol Sulfate inhalation solution is supplied as a 3 mL, clear, colorless, sterile, preservative free, aqueous solution in unit-dose low-density polyethylene (LDPE) vials. Each unit-dose LDPE vial is protected in a foil pouch, and each foil pouch contains 5 unit-dose LDPE vials. Each strength of Albuterol Sulfate inhalation solution is available in a shelf carton containing multiple foil pouches.
0.63 mg/3 mL solution (0.021%) and 1.25 mg/3 mL solution (0.042%) formulations: Indicated for the relief of bronchospasm in patients 2 to 12 years of age with asthma (reversible obstructive airway disease)
2.5 mg/3 mL solution (0.083%) formulation: Indicated for the relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm
Recommended Dose:
0.63 mg/3 mL solution (0.021%) and 1.25 mg/3 mL solution (0.042%) formulations:
- The usual starting dosage for patients 2 to 12 years of age is 1.25 mg or 0.63 mg of albuterol sulfate inhalation solution administered three or four times daily, as needed, by nebulization. More frequent administration is not recommended.
- Patients 6 to 12 years of age with more severe asthma (baseline FEV1 less than 60% predicted), weight > 40 kg, or patients 11 to 12 years of age may achieve a better initial response with the 1.25 mg dose.
- If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma which would require reassessment of therapy.
2.5 mg/3 mL solution (0.083%) formulation:
- The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. Children weighing < 15 kg who require < 2.5 mg/dose (i.e., less than a full vial) should use albuterol inhalation solution, 0.5% instead of albuterol inhalation solution, 0.083%. More frequent administration or higher doses are not recommended.
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- J45.20 - Mild intermittent asthma, uncomplicated;
- J45.21 - Mild intermittent asthma with (acute) exacerbation;
- J45.22 - Mild intermittent asthma with status asthmaticus;
- J45.30 - Mild persistent asthma, uncomplicated;
- J45.31 - Mild persistent asthma with (acute) exacerbation;
- J45.32 - Mild persistent asthma with status asthmaticus;
- J45.40 - Moderate persistent asthma, uncomplicated;
- J45.41 - Moderate persistent asthma with (acute) exacerbation;
- J45.42 - Moderate persistent asthma with status asthmaticus;
- J45.50 - Severe persistent asthma, uncomplicated;
- J45.51 - Severe persistent asthma with (acute) exacerbation;
- J45.52 - Severe persistent asthma with status asthmaticus;
- J45.901 - Unspecified asthma with (acute) exacerbation;
- J45.902 - Unspecified asthma with status asthmaticus;
- J45.909 - Unspecified asthma, uncomplicated;
- J45.990 - Exercise induced bronchospasm;
- J45.991 - Cough variant asthma;
- J45.998 - Other asthma;
- J98.01 - Acute bronchospasm
- Providers must bill with HCPCS code: J7613 - Albuterol, inhalation solution, FDA-approved final product, non-compounded, unit dose, 1 mg
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $0.04
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 00378-6991-52, 00378-6991-98, 00378-6992-52, 00378-6992-98, 00378-8270-31, 00378-8270-52, 00378-8270-55, 00378-8270-62, 00378-8270-64, 00378-8270-91, 00378-8270-93, 00487-0301-01, 00487-9501-00, 00487-9501-01, 00487-9501-03, 00487-9501-25, 00487-9501-60, 00487-9904-01, 00487-9904-25, 00591-3467-53, 00591-3468-53, 00591-3797-30, 00591-3797-60, 00591-3797-83, 47335-0703-48, 47335-0703-49, 47335-0703-52, 47335-0703-54, 60687-0395-79, 60687-0395-83, 76204-0010-01, 76204-0010-05, 76204-0010-11, 76204-0010-55, 76204-0011-01, 76204-0011-05, 76204-0011-11, 76204-0011-55, 76204-0200-01, 76204-0200-25, 76204-0200-30, 76204-0200-60
- 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