Effective with date of service Dec. 15, 2022, Medicaid and NC Health Choice programs cover mirvetuximab soravtansine-gynx injection, for intravenous use (Elahere) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Strength/Package Size: Injection: 100 mg/20 mL (5 mg/mL) in a single-dose vial.
Indicated for the treatment of adult patients with FRα positive, platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer, who have received one to three prior systemic treatment regimens. Select patients for therapy based on an FDA-approved test.
Recommended Dose: The recommended dose of Elahere is 6 mg/kg adjusted ideal body weight administered as an intravenous infusion every three weeks until disease progression or unacceptable toxicity. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- 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
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $67.17600
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 72903-0853-01
- 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