Strength/Package Sizes: Injection: 1 mg/mL solution in a single-dose vial; 30 mg/30 mL (1 mg/mL) solution in a single-dose vial.
Mosunetuzumab-axgb injection is indicated for the treatment of adult patients with relapsed or refractory follicular lymphoma after two or more lines of systemic therapy.
Recommended Dose: Administer for 8 cycles (21-day treatment cycles), unless patients experience unacceptable toxicity or disease progression. For patients who achieve a complete response, no further treatment beyond 8 cycles is required. For patients who achieve a partial response or have stable disease in response to treatment with Lunsumio after 8 cycles, an additional 9 cycles of treatment (17 cycles total) should be administered, unless a patient experiences unacceptable toxicity or disease progression. Cycle 1 Day 1 – 1 mg; Cycle 1 Day 8 – 2 mg; Cycle 1 Day 15 – 60 mg; Cycle 2 Day 1 – 60 mg; Cycle 3+ Day 1 – 30 mg. See full prescribing information for further detail.
Medicaid and Health Choice Billing
ICD-10-CM Diagnosis Codes Required for Billing
C82.01 - Follicular lymphoma grade I, lymph nodes of head, face, and neck;
C82.02 - Follicular lymphoma grade I, intrathoracic lymph nodes;
C82.03 - Follicular lymphoma grade I, intra-abdominal lymph nodes;
C82.04 - Follicular lymphoma grade I, lymph nodes of axilla and upper limb;
C82.05 - Follicular lymphoma grade I, lymph nodes of inguinal region and lower limb;
C82.06 - Follicular lymphoma grade I, intrapelvic lymph nodes;
C82.07 - Follicular lymphoma grade I, spleen;
C82.08 - Follicular lymphoma grade I, lymph nodes of multiple sites;
C82.09 - Follicular lymphoma grade I, extranodal and solid organ sites;
C82.11 - Follicular lymphoma grade II, lymph nodes of head, face, and neck;
C82.12 - Follicular lymphoma grade II, intrathoracic lymph nodes;
C82.13 - Follicular lymphoma grade II, intra-abdominal lymph nodes;
C82.14 - Follicular lymphoma grade II, lymph nodes of axilla and upper limb;
C82.15 - Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb;
C82.16 - Follicular lymphoma grade II, intrapelvic lymph nodes;
C82.17 - Follicular lymphoma grade II, spleen;
C82.18 - Follicular lymphoma grade II, lymph nodes of multiple sites;
C82.19 - Follicular lymphoma grade II, extranodal and solid organ sites;
C82.21 - Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck;
C82.22 - Follicular lymphoma grade III, unspecified, intrathoracic lymph nodes;
C82.23 - Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes;
C82.24 - Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb;
C82.25 - Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb;
C82.26 - Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes;
C82.27 - Follicular lymphoma grade III, unspecified, spleen;
C82.28 - Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites;
C82.29 - Follicular lymphoma grade III, unspecified, extranodal and solid organ sites;
C82.31 - Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck;
C82.32 - Follicular lymphoma grade IIIa, intrathoracic lymph nodes;
C82.33 - Follicular lymphoma grade IIIa, intra-abdominal lymph nodes;
C82.34 - Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb;
C82.35 - Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb;
C82.36 - Follicular lymphoma grade IIIa, intrapelvic lymph nodes;
C82.37 - Follicular lymphoma grade IIIa, spleen;
C82.38 - Follicular lymphoma grade IIIa, lymph nodes of multiple sites;
C82.39 - Follicular lymphoma grade IIIa, extranodal and solid organ sites;
C82.41 - Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck;
C82.42 - Follicular lymphoma grade IIIb, intrathoracic lymph nodes;
C82.43 - Follicular lymphoma grade IIIb, intra-abdominal lymph nodes;
C82.44 - Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb;
C82.45 - Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb;
C82.46 - Follicular lymphoma grade IIIb, intrapelvic lymph nodes;
C82.47 - Follicular lymphoma grade IIIb, spleen;
C82.48 - Follicular lymphoma grade IIIb, lymph nodes of multiple sites;
C82.49 - Follicular lymphoma grade IIIb, extranodal and solid organ sites;
C82.51 - Diffuse follicle center lymphoma, lymph nodes of head, face, and neck;
C82.52 - Diffuse follicle center lymphoma, intrathoracic lymph nodes;
C82.53 - Diffuse follicle center lymphoma, intra-abdominal lymph nodes;
C82.54 - Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb;
C82.55 - Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb;
C82.56 - Diffuse follicle center lymphoma, intrapelvic lymph nodes;
C82.57 - Diffuse follicle center lymphoma, spleen;
C82.58 - Diffuse follicle center lymphoma, lymph nodes of multiple sites;
C82.59 - Diffuse follicle center lymphoma, extranodal and solid organ sites;
C82.61 - Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck;
C82.62 - Cutaneous follicle center lymphoma, intrathoracic lymph nodes;
C82.63 - Cutaneous follicle center lymphoma, intra-abdominal lymph nodes;
C82.64 - Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb;
C82.65 - Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb;
C82.66 - Cutaneous follicle center lymphoma, intrapelvic lymph nodes;
C82.67 - Cutaneous follicle center lymphoma, spleen;
C82.68 - Cutaneous follicle center lymphoma, lymph nodes of multiple sites;
C82.69 - Cutaneous follicle center lymphoma, extranodal and solid organ sites;
C82.81 - Other types of follicular lymphoma, lymph nodes of head, face, and neck;
C82.82 - Other types of follicular lymphoma, intrathoracic lymph nodes;
C82.83 - Other types of follicular lymphoma, intra-abdominal lymph nodes;
C82.84 - Other types of follicular lymphoma, lymph nodes of axilla and upper limb;
C82.85 - Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb;
C82.86 - Other types of follicular lymphoma, intrapelvic lymph nodes;
C82.87 - Other types of follicular lymphoma, spleen;
C82.88 - Other types of follicular lymphoma, lymph nodes of multiple sites;
C82.89 - Other types of follicular lymphoma, extranodal and solid organ sites;
C82.91 - Follicular lymphoma, unspecified, lymph nodes of head, face, and neck;
C82.92 - Follicular lymphoma, unspecified, intrathoracic lymph nodes;
C82.93 - Follicular lymphoma, unspecified, intra-abdominal lymph nodes;
C82.94 - Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb;
C82.95 - Follicular lymphoma, unspecified, lymph nodes of inguinal region and lower limb;
C82.96 - Follicular lymphoma, unspecified, intrapelvic lymph nodes;
C82.97 - Follicular lymphoma, unspecified, spleen;
C82.98 - Follicular lymphoma, unspecified, lymph nodes of multiple sites;
C82.99 - Follicular lymphoma, unspecified, extranodal and solid organ sites
- Providers must bill with HCPCS code J9999 - Not otherwise classified, antineoplastic.
- One Medicaid and NC Health Choice unit of coverage is 1 mg.
- Maximum reimbursement rate per unit is $641.58300.
- Providers must bill 11-digit NDCs and appropriate NDC units. NDCs are 50242-0142-01, 50242-0159-01.
- 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