Effective with date of service Oct. 5, 2022, the Medicaid and NC Health Choice programs cover Bevacizumab-maly injection, for intravenous use (Alymsys) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs
Strength/Package Sizes: Injection: 100 mg/4 mL (25 mg/mL) or 400 mg/16 mL (25 mg/mL) in a single-dose vial
Indicated for the treatment of:
- Metastatic colorectal cancer, in combination with intravenous Fluorouracil-based chemotherapy for first- or second-line treatment
- Metastatic colorectal cancer, in combination with Fluoropyrimidine-Irinotecan- or Fluoropyrimidine-Oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line Bevacizumab product-containing regimen
- In combination with Atezolizumab for the treatment of patients with unresectable or metastatic hepatocellular carcinoma (HCC) who have not received prior systemic therapy (per NCCN guidelines)
Limitations of Use: Alymsys is not indicated for adjuvant treatment of colon cancer
- Unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer, in combination with Carboplatin and Paclitaxel for first-line treatment
- Recurrent glioblastoma in adults
- Metastatic renal cell carcinoma in combination with Interferon alfa
- Persistent, recurrent, or metastatic cervical cancer, in combination with Paclitaxel and Cisplatin, or Paclitaxel and Topotecan
- Epithelial ovarian, fallopian tube, or primary peritoneal cancer in combination with Paclitaxel, pegylated liposomal Doxorubicin, or Topotecan for platinum-resistant recurrent disease who received no more than 2 prior chemotherapy regimens
Recommended Dose (see full prescribing information for further detail):
Metastatic colorectal cancer
- 5 mg/kg every 2 weeks with bolus-IFL
- 10 mg/kg every 2 weeks with FOLFOX4
- 5 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks with Fluoropyrimidine-Irinotecan- or Fluoropyrimidine-Oxaliplatin-based chemotherapy after progression on a first-line Bevacizumab product-containing regimen
First-line non−squamous non−small cell lung cancer
- 15 mg/kg every 3 weeks with Carboplatin and Paclitaxel
Recurrent glioblastoma
- 10 mg/kg every 2 weeks
Metastatic renal cell carcinoma
- 10 mg/kg every 2 weeks with Interferon alfa
Persistent, recurrent, or metastatic cervical cancer
- 15 mg/kg every 3 weeks with Paclitaxel and Cisplatin, or Paclitaxel and Topotecan
Platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer
- 10 mg/kg every 2 weeks with Paclitaxel, pegylated liposomal Doxorubicin, or Topotecan given every week
- 15 mg/kg every 3 weeks with Topotecan given every 3 weeks
Hepatocellular Carcinoma
- 15 mg/kg after administration of 1,200 mg of Atezolizumab every 3 weeks
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
Colorectal cancer:
C18.0 - Malignant neoplasm of cecum;
C18.1 - Malignant neoplasm of appendix;
C18.2 - Malignant neoplasm of ascending colon;
C18.3 - Malignant neoplasm of hepatic flexure;
C18.4 - Malignant neoplasm of transverse colon;
C18.5 - Malignant neoplasm of splenic flexure;
C18.6 - Malignant neoplasm of descending colon;
C18.7 - Malignant neoplasm of sigmoid colon;
C18.8 - Malignant neoplasm of overlapping sites of colon;
C19 - Malignant neoplasm of rectosigmoid junction;
C20 - Malignant neoplasm of rectum;
C21.8 - Malignant neoplasm of overlapping sites of rectum, anus and anal canal;
Non-small cell lung cancer:
C33 - Malignant neoplasm of trachea;
C34.01 - Malignant neoplasm of right main bronchus;
C34.02 - Malignant neoplasm of left main bronchus;
C34.11 - Malignant neoplasm of upper lobe, right bronchus or lung;
C34.12 - Malignant neoplasm of upper lobe, left bronchus or lung;
C34.2 - Malignant neoplasm of middle lobe, bronchus or lung;
C34.31 - Malignant neoplasm of lower lobe, right bronchus or lung;
C34.32 - Malignant neoplasm of lower lobe, left bronchus or lung;
C34.81 - Malignant neoplasm of overlapping sites of right bronchus and lung;
C34.82 - Malignant neoplasm of overlapping sites of left bronchus and lung;
Cervical cancer:
C53.0 - Malignant neoplasm of endocervix;
C53.1 - Malignant neoplasm of exocervix;
C53.8 - Malignant neoplasm of overlapping sites of cervix uteri;
Renal cell carcinoma:
C64.1 - Malignant neoplasm of right kidney, except renal pelvis;
C64.2 - Malignant neoplasm of left kidney, except renal pelvis;
C65.1 - Malignant neoplasm of right renal pelvis;
C65.2 - Malignant neoplasm of left renal pelvis;
Glioblastoma:
C71.0 - Malignant neoplasm of cerebrum, except lobes and ventricles;
C71.1 - Malignant neoplasm of frontal lobe;
C71.2 - Malignant neoplasm of temporal lobe;
C71.3 - Malignant neoplasm of parietal lobe;
C71.4 - Malignant neoplasm of occipital lobe;
C71.5 - Malignant neoplasm of cerebral ventricle;
C71.6 - Malignant neoplasm of cerebellum;
C71.7 - Malignant neoplasm of brain stem;
C71.8 - Malignant neoplasm of overlapping sites of brain;
Epithelial ovarian, fallopian tube and primary peritoneal cancer:
C48.1 - Malignant neoplasm of specified parts of peritoneum;
C48.8 - Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum;
C56.1 - Malignant neoplasm of right ovary;
C56.2 - Malignant neoplasm of left ovary;
C56.3 - Malignant neoplasm of bilateral ovaries;
C57.01 - Malignant neoplasm of right fallopian tube;
C57.02 - Malignant neoplasm of left fallopian tube;
C79.61 - Secondary malignant neoplasm of right ovary;
C79.62 - Secondary malignant neoplasm of left ovary;
C79.63 - Secondary malignant neoplasm of bilateral ovaries;
HCC:
C22.0 - Liver cell carcinoma;
C22.8 - Malignant neoplasm of liver, primary, unspecified as to type
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
- One Medicaid and NC Health Choice unit of coverage is: 10 mg
- The maximum reimbursement rate per unit is: $77.61
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 70121-1754-01, 70121-1754-07, 70121-1755-01, 70121-1755-07
- 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