Effective with date of service Oct. 19, 2022, the Medicaid and NC Health Choice programs cover Sodium Thiosulfate injection, for intravenous use (Pedmark) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Size: Injection: 12.5 grams/100 mL in a single-dose vial
Indicated to reduce the risk of ototoxicity associated with Cisplatin in pediatric patients 1 month of age and older with localized, non-metastatic solid tumors.
Limitations of Use:
The safety and efficacy of Pedmark have not been established when administered following Cisplatin infusions longer than 6 hours. Pedmark may not reduce the risk of ototoxicity when administered following longer Cisplatin infusions, because irreversible ototoxicity may have already occurred.
Recommended dose (is based on surface area according to actual body weight)
- Less than 5 kg: 10 g/m2
- 5 to 10 kg: 15 g/m2
- Greater than 10 kg: 20 g/m2
Administer Pedmark as an intravenous infusion over 15 minutes, following Cisplatin infusions that are 1 to 6 hours in duration.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- T45.1X5A - Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter;
- T45.1X5D - Adverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter;
- T45.1X5S - Adverse effect of antineoplastic and immunosuppressive drugs, sequela
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $0.98
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 73077-0010-01
- 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